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2011-12062011 CMS Web Portal User Manual

1. e The proposed settlement amount is less than or equal to 25 000 for beneficiaries e The proposed settlement amount is less than or equal to 250 000 for non beneficiaries e The case already exists in the system use Case Lookup to work the case CMTS Workers Compensation Set Aside Web Portal CENTERS for MEDICARE MEDICAID SERVICES Home About This Site CMS Links How To Reference Materials Contact Us Logoff New Case Creation Sead See Help About This Page The information requested below will be systematically validated to ensure the Workers Compensation Medicare Set Aside WCMSA case does not already exist in the Web portal and that the data entered meets the criteria set for new case creation Anew WCMSA case should not be created if the beneficiary is deceased or the proposed settlement amount is under the threshold limits set for a WCMSA case Once the information is validated you can continue adding case information upload corresponding documentation in PDF file format and if ary create a work in progress case A work in progress case allows you to enter part of the new case information and save it to the MSAP The information saved will be available when you return to the portal to complete the new case creation process To begin the new case creation process enter the required data and click the Continue button To cancel the case creation click the Cancel button to retu
2. CENTERS for MEDICARE amp MEDICAID SERVICES Centers for Medicare amp Medicaid Services Office of Financial Management Financial Services Group 7500 Security Blvd Baltimore MD 21244 1850 Workers Compensation Medicare Set Aside Portal WCMSAP User Manual Rev 2011 6 December GHI DI 174 3 1 WCMSAP User Manual Table of Contents Table of Contents Chapter 1 Introduction ssssccsscscscscsscccscscscscscsssscssscsesssecsscesscesecssessscssscssssssssssssesssssecsseesscesocssesssessscsssessssssseeees 1 OVEN VIEW ios bisa os dog an ata ete th Bea Oat 1 ACCOUNE TY DOS Ma A AAA a 1 User ROL OS iis A A A A A A iva Soe eee 2 Account Representative AR Role iresi coeno toores isoset ores EEE cn neon nono conoce Ce SISE EEEE VEKKE DEEI arranca 2 Account Manager AM Role riere e ia se E EE e E E tule ETE AE 2 Account Designee AD Role cion it onas eo aes oTe a ea Oro Ee EAE dois de cio 3 Login ID and Pass word Limits si 25 sce ccs sige oeste iersinii dde oei E Ee EE araea CoE EKo Eoee resis 3 Electronic Data Interchange EDI Representative Suppoftt sssssssssessesesesrsreesssresssrssresesreesesresrsrernresesrresesreersseee 4 Chapter 2 WCMSAP Welcome Page seseessesessossesoosseseosoesessossesoessesossossessossesoessesoesseseesossessossesoessesoesoesessossessessesoss 5 ATL Menis s giese E NN 6 Bulletin TN AA O EO e SATE S E ASEAS EEEIEE iE aa 6 NEW REGISUVALLON ARA A E ON 7 VRATIN
3. Zip Code 1 OR Claim Number Workers Compensation WC Carrier Page Field Description Insurer Name Enter the carrier company name Address Line 1 Enter the first line of the carrier s mailing address Address Line 2 Enter the second line of the carrier s mailing address Optional City Enter the city where the carrier is located State Select the state where the carrier is located from the dropdown list Zip Code Enter the carrier s zip code The ZIP 4 field is optional Phone Enter the carrier s phone number The extension field is optional Fax Enter the carrier s fax number Optional E Mail Enter the carrier s E mail address Optional Re enter E mail Re enter the carrier s E mail address The address must be manually entered it cannot be copied and pasted This field is required if an E mail address is entered in the previous field Policy Number Enter the claimant s policy number with the WC carrier Do not enter hyphens Required if a Claim Number is not entered Do not enter a policy number and claim number Claim Number Enter the claimant s claim number with the WC carrier Do not enter hyphens Required if a Policy Number is not entered Do not enter a policy number and claim number Rev 2011 6 Decemb
4. To delete documentation locate the document and click the Delete button that appears to the right of the file name This will permanently remove the document from the Web Portal You will not be able to delete any files that were uploaded to the WCMSA Web Portal when the case was submitted An asterisk indicates a required file 05 Submitter Letter or Other Summary Documents Submitter Letter pdf 2010 01 20 Delete Add Files Replace Files Typically documents must be replaced when a case has been submitted and it contains co mingled documents Only files that have been flagged as replaceable by the WCRC can be replaced A co mingled alert will be listed on the Alert Lookup page in this instance See Chapter 12 for more information about alerts If a document must be replaced click the Replace link that appears to the right of the file name _Benefician Claimant Diagnosis Codes WCHCamier Employer Attorney Notes Documents Summary Case Documents QUICK HELP Below is a list of the documentation that is attached to this case To add documentation to the case click the Add Files link under the document type you would like to add Documents must be in PDF file format and cannot exceed 40 MB megabytes total size for up to 3 files Help About This Page To delete documentation locate the document and click the Delete button that appears to the right of the file name This
5. Sent Wednesday April 01 2009 2 42 PM To AAAAAQAAA COM Subject Workers Compensation Medicare Set Aside Portal WCMSAP Successful Vetting Verification Company Name AAAAAAAAAAAA Authorized Representative FIRST LAST Your organization has been successfully verified and registered for the Workers Compensation Set Aside Portal WCMSAP In order to use the WCMSAP you must complete the account setup process A letter will be sent via the U S Postal Service which contains your Account Identification ID and Personal Identification Number PIN You will need this information in order to complete the final step of the account setup If you have any questions or concerns please contact our Electronic Data Interchange EDI Department Phone 646 458 6740 E mail COBVA GHIMedicare com Confidentiality Note This electronic message transmission is intended only for the person or entity to which it is addressed and may contain information that is privileged confidential or otherwise protected from disclosure If you have received this transmission but are not the intended recipient you are hereby notified that any disclosure copying distribution or use of the contents of this information is strictly prohibited If you have received this e mail in error please contact the COBC Electronic Data Interchange EDI Department at 646 458 6740 and delete and destroy the original message and all copies TK KK Rev 2011 6 Decem
6. AHH HHH HHHH Address AAAAAAAAAAAA AAAAAAAAAAAA AAAAAAAAAAAA St HHEHEH H EHH F E mail AMemail address com Account ID Account Type Self Date 99 99 9999 COBC EDI Contact Information E mail COBVA GHIMedicare com Phone 646 458 6740 SAFEGUARDING amp LIMITING ACCESS TO EXCHANGED DATA I the undersigned Account Manager for the WCMSA Self account defined above certify that the information contained in this Registration is true accurate and complete to the best of my knowledge and belief and I authorize CMS to verify this information I agree to establish and implement proper safeguards against unauthorized use and disclosure of the data for the purposes of WCMSA proposal s review and processing Proper safeguards shall include the adoption of policies and procedures to ensure that the data obtained shall be used solely in accordance with Section 1106 of the Social Security Act 42 U S C 1306 Section 1874 b of the Social Security Act 42 U S C 1395k b Section 1862 b of the Social Security Act 42 U S C 1395y b and the Privacy Act of 1974 as amended 5 U S C 552a The WCMSA authorized representative shall establish appropriate administrative technical procedural and physical safeguards to protect the confidentiality of the data and to prevent unauthorized access to the data provided by the CMS I agree that the authorized representatives of the CMS shall be granted access to premises where the Medicar
7. If you enter the HICN you can NOT enter an SSN Bene Health Insurance Claim Number HICN Rev 2011 6 December 17 WCMSAP User Manual Chapter 3 New Registration Beneficiary Information Page Field Description Bene Social Security Enter the beneficiary s SSN Number SSN If you enter the SSN you can NOT enter a HICN Bene Date Of Birth Enter the beneficiary s date of birth Bene Gender Select the beneficiary s gender from the drop down list Command Buttons Previous Click to return to the Representative Information page Next Click to save changes and continue to the next page 3 Enter the required information then click Next The Registration Summary page displays This page lists all the information that was previously entered All information should be reviewed and verified before continuing CENTERS for MEDICARE amp MEDICAJO SERVICES Home Registration Summary About This Site CATS Workers Compensation Medicare Set Aside Web Portal o CMS Links How To Reference Materials Account Type Representative B fici Inf ti Representative Information eneticiary Information S q t Name LAST First Initial F First Name FIRST MI M Last Name LAST Last Name LAST First Initial SSN AAR HICN HHHHHH E Mail Address AAAAAAAAAAAA Date of Birth MONTH HH G Male Phone 444 43444 ext He Gender Male Fax HA HE Representative
8. Next Click to save changes and continue to the next page Cancel Click to cancel the registration process Information entered on the current page and any previous pages is NOT saved Rev 2011 6 December 12 WCMSAP User Manual Chapter 3 New Registration 2 Enter the requested information then click the Next button The Account Representative AR Information page displays This page captures information related to the AR As the AR you must enter your personal information on this page Note An AR can only have that one role the AR cannot function as an Account Manager or an Account Designee E mail addresses for each user role will be verified upon entry and any address matches between AM AD and AR roles will be denied Fields marked with an asterisk are required CATS CENTERS for MEDICARE amp MEDICAID SERVICES Workers Compensation Set Aside Web Portal Home About This Site CMS Links How To Reference Materials Contact Us Logoff Account Representative AR Information An asterisk indicates a required field Help About This Page AR First Name MI Last Name AR Title AR E Mail Address AR Re enter E Mail Address AR Phone E 7 ext AR Fax Previous Next Cancel Account Representative AR Information Page Field Description AR First
9. Password o ooo Forgot Password This displays the Forgot Password page Enter your Login ID and click Continue CATS Workers Compensation Set Aside Web Portal About This Site CMS Links How To Reference Materials Contact Us Forgot Password An asterisk indicates a required field Login ID Gara Rev 2011 6 December 39 WCMSAP User Manual Chapter 5 Login 3 The page then re displays with the two Security Questions you selected during the registration process Correctly answer each of your pre selected Security Questions then click the Continue button If the information you entered is correct your new temporary Password will be sent via E mail CMTS Workers Compensation Set Aside Web Portal CENTERS for MEDICARE 8 MEDICAID SERVICES About This Site CMS Links How To Reference Materials Contact Us Forgot Password QUICK HELP An asterisk indicates a required field Help About This Page Security Question 1 What city were you born Answer 1 Security Question 2 What is your father s middle name Answer 2 Continue If you receive an error indicating that your answers are incorrect check your answers and re enter If you cannot remember the answers to your Security Questions contact a COBC EDI representative 4 The Thank You page displays if your answers are correct indicating that the system has generated a temporary Password and sent it to y
10. Select Y Zip Code Phone State where injury occurred Select v Submitter Type Select v Save Work In Progress Case Summary Cancel Case Creation For Self accounts Most fields are pre populated If the name address or phone number information is no longer correct click the Cancel Case Creation button make the necessary corrections via the Update Personal Information page then begin the case creation process again For Corporate and Representative accounts The information entered on the previous page is pre populated with all other fields open for editing Beneficiary HICN Displays the beneficiary s HICN if previously entered The first 5 digits are masked with asterisks Beneficiary Claimant Displays the beneficiary or claimant s social security number if previously entered SSN The first 5 digits are masked with asterisks Beneficiary Claimant Displays the beneficiary or claimant s birth date Date of Birth Rev 2011 6 December 65 WCMSAP User Manual Chapter 10 Create a New Case Beneficiary Claimant Information Page E E ee Beneficiary Claimant Displays the beneficiary or claimant s gender Gender Address Line 1 Enter the first line of the beneficiary or claimant s mailing address This field is pre populated for Self account types Address Line 2 Enter the second line of the beneficiary or claimant s mailing address Optional This field is pre populated for Self account types if pr
11. Self Account Type After all information has been verified by the system the Account Setup Self Beneficiary Information page displays The Self Beneficiary Information page displays information entered during the initial registration process CMTS Workers Compensation Medicare Set Aside Web Portal CENTERS for MEDICARE amp MEDICAID SERVICES Home About This Site CMS Links How To Reference Materials Contact Us Logoff Account Setup Self Beneficiary Information First Name FiRsT MI M Last Name LAST Phone 44 HHH Mailing Address Address Line 1 AAv Address Line 2 AA Zip Code HEHHEHE HHH Review the listed information and click the Next button If any of the listed information is incorrect contact a COBC EDI representative to have it corrected Rev 2011 6 December WCMSAP User Manual Chapter 4 Account ID Setup amp Account Manager Registration Account Manager AM Self Registration The Account Manager AM controls the administration of a WCMSAP account The AM has the following responsibilities e Reviews signs and returns the Profile Report upon its receipt in order to be granted full access to all WCMSAP functionality For Corporate accounts the AR signs the Profile Report e Manages the WCMSAP account s information and updates general account information e Invites other users to function as Account Designees ADs ADs are for Corporate or Representativ
12. If you do not have the pass phrase please contact the above Account Manager If you have already registered please visit the Workers Compensation Medicare Set Aside Welcome Page at https Awww cab cms hhs gowVVCMSA to login Enter the ic passphrase You must read the User Agreement provided in the scrolling box To accept the agreement click the checkbox You must accept and agree to the terms of the User Agreement in order to continue through the registration process View and print the agreement below me User Agreement THE FOLLOWING DESCRIBES THE TERMS AND CONDITIONS BY WHICH THE CENTERS FOR MEDICARE MEDICAID SERVICES CMS OFFERS YOU ACCESS TO THE COORDINATION OF BENEFITS COB SECURE WEB SITE You must read and accept the terms and conditions contained in this User Agreement expressly set out below and incorporated by reference before you may access the COB Secure Web site v Please check the following box E accept the User Agreement and Privacy Policy above Privacy Policy User Agreement 5 The Registration page informs you that you have been assigned as an AD for the listed Account ID Enter the Passphrase given to you earlier by the Account Manager check the Accept box beneath the DUA and click the Next button Note The Passphrase is case sensitive Enter it exactly as it was given to you 6 The Designee Personal Information page displays Rev 2011 6 December 58 WCMSAP User Manual
13. Mailing Address Address Line 1 AAAAAAAAA AA Address Line 2 City AAAAAAAAAAAA State AAAAAAAAAAAA M Workers Compensation Set Aside Web Portal Contact Us QUICK HELP Help About This Page 3 Your current personal information is displayed with all fields except Date of Birth open for editing After making any necessary changes click the Next button This displays the Personal Information Update Confirmation page showing the updated information CATS CENTERS for MEDICARE amp MEDICAID SERVICES Reference Materials About This Site CMS Links Personal Information Update Confirmation Your information has been updated Print this page for your records Personal Information First Name FIRST MI M Last Name LAST E Mail Address AAAAAAAAAA Phone HHHHE ext HHH Mailing Address Address Line 1 AAAAAAAAAA Address Line 2 AAAAAAAAAAAA City AAAAAAAAAAA State AAAAAAAAAAAA Zip Code 444 Return to Home Workers Compensation Set Aside Web Portal Contact Us ra B Print this page 5 Click the Return to Home button to return to the Home page The system then sends you an E mail indicating that your personal information has been changed Rev 2011 6 December 43 WCMSAP User Manual Chapter 7 Account Settings Update Account Information 1 On the Home page click the Update Account Information link in the Accoun
14. Medicaid Services The information provided is complete truthful accurate and meets all requirements set forth to use this process and have read and understand all of the Centers for Medicare amp Medicaid Services information at http Wwww cms gowWorkersCompAgencySerices LOG OFF IMMEDIATELY if you do not agree to the conditions stated in this warning Accept lin 1 A Privacy Act system of records is a group of any records about individuals and under the control of any Federal agency from which information is retrieved by the name or other personal identifier of the individual 3 Review the DUA To proceed click the I Accept link at the bottom of the page You will be denied access to the WCMSAP site if you click I Decline 4 The WCMSAP Welcome page displays Rev 2011 6 December WCMSAP User Manual Chapter 3 New Registration CMTS Workers Compensation Medicare Set Aside Web Portal CENTERS for MEDICARE amp MEDICAID SERVICES About This Site CMS Links How To Reference Materials Contact Us Welcome to the WCMSAP This site provides an interface for entry of Workers Compensation Medicare Set Aside Arrangements WCMSA proposals Attorneys Medicare beneficiaries claimants insurance carriers and VWWCMSA vendors may use this site to enter the case information directly The site also provides attorneys Sign into your account Medicare beneficiaries claimants insurance carriers and WCMSA
15. RE Workers Compensation Medicare Set aside Arrangement for Claimant Claimant HICN HICN SSN SSN Date of Injury DateOfInjury CMS Case Control Number CaseNo The CMS has received your request to review a proposed Workers Compensation Medicare Set aside Arrangement WCMSA for the claimant listed above Please note that the items indicated on the enclosure are missing from the above referenced case and a review of the proposed WCMSA cannot be completed without this information The requested information must include the CMS Case Control Number listed above and be appended to the case according to the information provided on the enclosure no later than 10 business days from the date of this letter Failure to provide the information requested may result in closing your case as CMS will not have sufficient information to review the WCMSA proposal As a result Medicare may exclude its payments for medical expenses related to the injury ies and or illness es disease s until such time as workers compensation settlement funds expended for services otherwise reimbursable by Medicare exhaust the entire settlement When all requested information is received CMS will then review the proposed WCMSA and send a response to the appropriate parties with regard to the findings of the review Questions regarding this correspondence may be directed to RoName at RoPhone Sincerely RoName2 Enclosure CC Cl
16. citic admin unisys pwd security 76543210 43210 098765 iraq ois tmg internet intranet extranet att Lockheed Rev 2011 6 December 59 WCMSAP User Manual Chapter 9 Account Designee Registration CATS CENTERS for MEDICARE amp MEDICAID SERVICES Workers Compensation Set Aside Web Portal Home About This Site CMS Links How To Reference Materials Contact Us Logoff Designee Login Information The security information requested on this page will allow the system to authenticate your identity each QUICK HELP time you log on This will ensure only you are provided access and updating priviledges Help About This Page Choose your Login ID and password carefully e Password must be changed every sixty 60 days Password must consist of at least eight 8 characters Password must contain at least one upper case letter one lower case letter one number and one special character e Password must contain a minimum of four 4 changed characters from the previous password Password cannot be changed more than once per day e Password must be different from the previous 6 passwords e Password cannot contain a reserved word See Help About This Page for a complete list An asterisk indicates a required field Logo A Password po Re enter Password MA E The Security Questions allow you to regain account access if you forget your password Please note the answers you provide to these q
17. excess of granted authority such as access through use of another s Login ID and or password may be in violation of federal law including the False Claims Act the Computer Fraud and Abuse Act and other relevant provisions of federal civil and criminal law Violators may be subject to administrative disciplinary action and civil and criminal penalties including civil monetary penalties For site security purposes we employ software programs to monitor and identify unauthorized access unauthorized attempts to upload or change information or attempts to otherwise cause damage In the event of authorized law enforcement investigations and pursuant to any required legal process information from these sources may be used to help identify an individual and may be used for administrative criminal or other adverse action Privacy Act Statement The collection of this information is authorized by 42 U S C 1395y b 5 The information collected will be used to identify and recover past mistaken Medicare primary payments and to prevent Medicare from making mistakes in the future for those Medicare Secondary Payer situations that continue to exist Attestation of Information have submitted all relevant information obtained and or have knowledge of regarding this claimant that was generated at any time on or after the Date of Incident DOI for the alleged accidentillness injury incident at issue and has been included as part of this submission of
18. 5933 Date of Injury MONTH 4 HICN HHA SSN A WC Carrier Employer Insurer Name AAAAAAAAAAAS Empl Name AAAA AAAAAAAA Policy Number a pero amara EIN A Claim Number Panes After all changes are made click the Submit Files button at the bottom of the Case Summary page to save changes to the submitted case Click the New Search button to return to the Case Lookup page To manage case documents click the Add Files button on the Case Summary page This displays the Case Documents page Add Files On the Case Documents page click the Add Files link under the document category you would like to add This opens the Attach Documentation page Use the Attach Documentation page to browse your system and select a document to upload to the case Selected documents must be in PDF format and cannot exceed 40 MB total size for up to 3 files Document categories marked with an asterisk are required for submission See page 76 for more information on adding documents Rev 2011 6 December 83 WCMSAP User Manual Chapter 11 Manage Existing Cases Benefician Claimant Diagnosis Codes WCCamier Employer Attorney Notes Documents Summary Case Documents QUICK HELP Below is a list of the documentation that is attached to this case To add documentation to the case click the Add Files link under the document type you would like to add Documents must be in PDF file Help About This Page format
19. 6 December 10 WCMSAP User Manual Chapter 3 New Registration Workers Compensation Set Aside Web Portal Home About This Site CMS Links How To Reference Materials Contact Us Logoff Select Account Type Please select the type of account for which you are registering QUICK HELP Help About This Page OCorporate A corporate account type indicates that the submitter is registering as a corporate entity with an Employer Identification Number EIN and will be regularly submitting WCMSA requests O Representative A representative account type is for non corporate WCSA submitters These submitters do not have an EIN but will be submitting multiple cases O Self Self submitters are Medicare beneficiaries or future Medicare beneficiaries Claimant submitting a case on their own behalf The registrant must be a Medicare Beneficiary or Claimant and may only submit cases for themselves 7 Select an account type and click Next The next page that displays depends on the account type selected Rev 2011 6 December 11 WCMSAP User Manual Chapter 3 New Registration Corporate Account Type 1 For Corporate account types the Corporate Information page displays Enter the corporation s EIN and mailing address on this page This address will be used to send the Profile Report and any correspondence from the COBC regarding this Account ID Fields marked with an asterisk are required CATS CE
20. Chapter 9 Account Designee Registration CMTS Workers Compensation Set Aside Web Portal Home About This Site CMS Links How To Reference Materials Contact Us Logoff Designee Personal Information An asterisk indicates a required field First Name MI Last Name E mail Address AAAAAAAAAA prone EM en C Mailing Address Address Line 1 Address Line 2 City State Select Zincode 7 Enter the requested information and click the Next button 8 The Designee Login Information page displays Select 2 Security Questions and setup a Login ID and Password using the following guidelines e Passwords must be changed every 60 days e Passwords must be 8 characters in length e Passwords must contain at least one upper case letter one lower case letter one number and one special character e Passwords cannot be changed more than once per day e Passwords cannot contain 4 consecutive characters from the previous password e Passwords must be different from the last 6 Passwords e Passwords cannot contain a reserved word Password welcome hcfa cms system medicare medicaid temp letmein god sex money quest 1234 or f20asya ravens redskin orioles bullets capitol Maryland terps doctor 567890 12345678 root bossman january february march april may june july august september october november december ssa firewall
21. Creation Date Range From Date To enter an alert creation date range enter a beginning case creation date here To Date Enter an ending alert creation date here Alert Listing Alert ID ID number of the alert Click the Alert ID link to display the Alert Detail page The Alert Detail page contains the complete alert Creation Date Date the alert was created Type of alert Most alerts are a letter and the Alert Detail page will contain the letter in PDF format Options are e Below Threshold Development Deny Zero Set Aside Approval includes recommendation attachments Closeout Deceased Beneficiary does not produce a letter e Co Mingling does not produce a letter Case number associated with the alert Click the Case Number link to display the Alert Listing page which displays all alerts for that case Creator Entity that entered the alert Options are Submitter WCRC and RO Status Status of the alert Options are Open or Archived Alert Type Case Number The HICN or SSN of the beneficiary or claimant associated with the case The first 5 HICN SSN digits of the HICN or SSN are masked by asterisks Bene Name Name of the beneficiary or claimant associated with the case Command Buttons Search Click to narrow the displayed alerts using your search criteria Clear Click to empty all fields and show all alerts Cancel Click to return to the Home page Filter alert
22. Date j MM DD CCYY To Date MM DD CCYY Case Submission Date Range From Date MM DD CCYY To Date MM DD CCYY Case Lookup Page Field Description Enter the Case Number to narrow results The case number was provided when the Case Control Number case was submitted or saved as a Work In Progress Enter a Health Insurance Claim Number HICN E If you enter a HICN do not enter an SSN Enter a Social Security Number oon If you enter a SSN do not enter a HICN Case Creation From Date To enter a case creation date range enter a beginning case creation date here Case Creation To Date Enter an ending case creation date here Case Submission From Date To enter a case submission date range enter a beginning case submission date here Case Submission To Date Enter an ending case submission date here Rev 2011 6 December 79 WCMSAP User Manual Chapter 11 Manage Existing Cases Case Lookup Page Field Description Command Buttons Clear Click to reset all search options Cancel Click to return to the Home page Search Click to display search results After you have entered your search criteria click the Search button The Case Listing page displays Rev 2011 6 December 80 WCMSAP User Manual Chapter 11 Manage Existing Cases Case Listing The Cas
23. Description O 93 O 5933 Generalized Infection w Foreign Body in Larynx O 7933 Abdominal Swelling Select Diagnosis Code The Diagnosis Codes page redisplays with the new code added to the list at the bottom of the page To remove a diagnosis code from a case click the Delete icon x next to the code Diagnosis Code E j Add Diagnosis Code Delete Diagnosis Code Description x 933 Foreign Body in Larynx Save Work In Progress Cancel Case Creation Once all codes are added to the case click Next The Workers Compensation WC Carrier page displays Rev 2011 6 December 68 WCMSAP User Manual Chapter 10 Create a New Case Workers Compensation WC Carrier Enter the information for a single WC carrier insurer to the case Any additional WC carriers must be entered on the Case Notes page Fields marked with a superscript 1 are required Case Information Beneficiary Claimant Diagnosis Codes We Carrier Employer Attorney Notes l Documents Summary Workers Compensation WC Carrier QUICK HELP Insurer Name Address Line 1 Address Line 2 City Phone Fax E Mail Re enter E Mail Policy Number Tax ID Number TIN An superscripted indicates Rx PCN Rx BIN Save Work In Progress Case Summary Cancel Case Creation A Help About This Page a field is required for submission 1 1 State 1 lt
24. Mailing Address Address Line 1 AAAAAAAAAAAA Address Line 2 Previous Submit Registration Contact Us Logoff DR J Print this page 4 Verify that all information is correct To make any corrections click the Edit button next to the proper section to return to that page Once all corrections have been made click Next at the bottom of that page to navigate back to the Summary page After you have returned to the Registration Summary page click the Submit Registration button Click Previous to return to the Beneficiary Information page 5 After you click Submit Registration the Thank You page displays outlining the next steps in the registration process Rev 2011 6 December 18 WCMSAP User Manual Chapter 3 New Registration CMTS Workers Compensation Medicare Set Aside Web Portal CENTERS for MEDICARE amp MEDICAID SERVICES Home About This Site CMS Links How To Reference Materials Contact Us Logott Thank You A Print this page You have successfully completed the initial registration for the Workers Compensation Set Aside Web site Please print this page for your records Next Steps After initial registration is completed the information captured will be vetted to verify the Company Representative or Beneficiary Claimant is an appropriate submitter After the vetting has been completed the registrant will be defined with an Account identification number ID Aft
25. Secondary Payer recovery rights Medicare has both a direct recovery right and a subrogated right to recover Medicare payments related to any workers compensation WC settlement judgment award or other recovery Any payments Medicare may have made that are related to the WC settlement judgment award or other recovery must be repaid If you have further questions please contact RO ContactName at RO ContactNum Sincerely Ou Walic Gerald Walters Director Financial Services Group Office of Financial Management cc CcFields Rev 2011 6 December 111 WCMSAP User Manual Chapter 15 Sample WCMSAP Correspondence Below Threshold Letter Non Beneficiary CMTS CENTERS for MEDICARE amp MEDICAID SERVICES MEDICARE Coordination of Benefits MailDate MailTo RE Workers Compensation Medicare Set aside Arrangement for Claimant Claimant HICN HICN SSN SSN Date of Injury DateOfInjury CMS Case Control Number CaseNo The Centers for Medicare amp Medicaid Services CMS has received your correspondence regarding the proposed workers compensation WC settlement that includes future medical benefits for the above referenced claimant If the referenced Social Security Number SSN is incorrect you must provide CMS with the correct SSN or a Health Insurance Claim Number within 10 calendar days of the date of this letter CMS does not issue verification letters confirm
26. Services CMS has received your correspondence regarding the proposed workers compensation WC settlement If the referenced Health Insurance Claim Number HICN is incorrect you must provide CMS with the correct HICN within 10 business days of the date of this letter The CMS will only review new Workers Compensation Medicare Set aside Arrangement WCMSA proposals for Medicare beneficiaries when the total settlement amount is greater than 25 000 00 CMS does not issue verification letters confirming that approval of a Workers Compensation Medicare Set aside Arrangement is unnecessary when the WC settlement is 25 000 00 or less The CMS wishes to stress that this is a CMS workload management tool and not a substantive dollar or safe harbor threshold Therefore due to resource constraints CMS is not providing a review of this case because the facts represented do not meet the above thresholds However Medicare beneficiaries must still consider Medicare s interest in all WC cases and ensure that Medicare is secondary to WC in such cases For additional information and links to CMS memoranda and frequently asked questions documents please visit the Medicare Coordination of Benefits Workers Compensation website at http www cms hhs gov WorkersCompA gencyServices Please note that decisions regarding future medical treatment and or future prescription drug expenses are independent of any determination regarding Medicare
27. User Manual Chapter 10 Create a New Case Diagnosis Codes Add diagnosis codes to the case by entering a code in the Diagnosis Codes text box then clicking the Add Diagnosis Code button Click the Clear button to remove the value in the text box You must add at least one diagnosis code to the case and a maximum of 5 diagnosis codes The primary diagnosis code must be added first CMTS Workers Compensation Set Aside Web Portal CENTERS for MEDICARE amp MEDICAID SERVICES About This Site CMS Links How To Reference Materials Contact Us Case Information BeneficiaryiClaimant Diagnosis Codes WC Carrier d Employer Attorney i Notes Documents i Summary i Diagnosis Codes You may search for a diagnosis code by entering the code or by entering any text in the text field to find all the diagnoses whose description includes that text If you would like to perform a Diagnosis Code Lookup by the code or the description please Click on the Search link to go to the Diagnosis Code Lookup screen Diagnosis Code Search j2 Type the diagnosis code in the text box provided and click on the Add Diagnosis Code button to add the diagnosis code to the list At least one diagnosis code must be provided for the case The primary Diagnosis Code should be added first You may add up to 5 diagnosis codes to the case Click the Clear button to clear the value in the text box To delete a diagnosis code from the listing
28. a Medicare Beneficiary as appears on Medicare Card First Name MI Last Name uired if HICN is not provided Gender Select Phone 4 ext City State Select be Zip Code Beneficiary Claimant Information Page Field Description First Name Enter your first name as it appears on your Medicare Card if you are a Medicare Beneficiary If you are not a Medicare Beneficiary enter your Legal first name Enter your middle initial as it appears on your Medicare Card if you are a Medicare MI Beneficiary If you are not a Medicare Beneficiary enter your Legal middle initial Optional LastName Enter your last name as it appears on your Medicare Card if you are a Medicare Beneficiary If you are not a Medicare Beneficiary enter your Legal last name Health Insurance Claim Number HICN Enter your HICN If you enter the HICN you can NOT enter an SSN Rev 2011 6 December 20 WCMSAP User Manual Chapter 3 New Registration Beneficiary Claimant Information Page Field Description Social Security Number SSN Enter your SSN If you enter the SSN you can NOT enter a HICN Date Of Birth Enter your date of birth Gender Select your gender from the drop down list E mail Addres
29. a new case for this beneficiary or claimant Case Under Threshold If you receive this error message the proposed settlement amount is under threshold for the case threshold amounts must be greater than 25 000 for beneficiaries or greater than 250 000 for non beneficiaries and you will not be allowed to create a new case Case Submission Errors Invalid Diagnosis Code If you receive this error message the diagnosis code you entered on the Diagnosis Codes page does not exist in the database Use the Diagnosis Code Search page to retrieve the proper code Rev 2011 6 December 95 WCMSAP User Manual Chapter 14 Troubleshooting Incomplete Case Information This message is displayed on the Case Summary page if required sections of a newly created case are incomplete Any required fields that are missing or incomplete are highlighted in red and flagged with an asterisk Return to the incomplete incorrect sections and make corrections For any additional problems contact the COBC EDI Department at 646 458 6740 or by E mail at COBVA GHIMedicare com EDI representatives are available to assist you Monday through Friday excluding Federal holidays from 9 00 a m to 5 00 p m Eastern Time Rev 2011 6 December 96 WCMSAP USER MANUAL Chapter 15 Sample WCMSAP Correspondence System Generated E mails Successful Vetting Notification Corporate Account From cobva ghimedicare com mailto cobva O ghimedicare com
30. active only after all required case information has been entered and a consent form has been provided The Successful Case Submission page displays Workers Compensation Set Aside Web Portal Contact Us About This Site How To Reference Materials CMS Links Logoff Successful Case Submission You have successfully submitted Case Number 234576 You can return to the WCMSAP at a later time and work on the submitted case by using the case lookup process described in the next chapter and utilizing the case number provided on the Successful Case Submission page Rev 2011 6 December 77 WCMSAP USER MANUAL Chapter 11 Manage Existing Cases Users of the WCMSAP can access and make changes to cases under their assigned Account ID s Account Managers have access to all associated cases while Account Designees case access is controlled by the AM Use the case lookup process to perform the following functions Search for Work In Progress and Submitted cases View case information View case status Grant or revoke Account Designee access to specific cases AM function only Add additional documents to a case Delete documents from Work In Progress cases Replace co mingled documents on submitted cases Follow the steps detailed below to manage existing cases From the Home page click the Case Lookup link in the I d Like To box The Case Lookup page displays View Alerts I
31. application CATS Workers Compensation Medicare Set Aside Web Portal CENTERS for MEDICARE amp MEDICAID SERVICES About This Site CMS Links Reference Materials Contact Us e About This Site navigates to the How to Use This Site link offering general information on how to use the WCMSAP application e CMS Links provides links to the Workers Compensation Agency Services page the Medicare Web site and the Coordination of Benefits Web site e How To provides detailed information on performing the following functions Getting Started Requesting your Login ID Requesting your Password Changing your Password Resetting your PIN Changing your Account Manager Changing your Account Representative o Inviting Account Designees e Reference Materials provides a link to the WCMSAP User Manual this guide e Contact Us displays the following message CATS Workers Compensation Medicare Set Aside Web Portal CENTERS for MEDICARE amp MEDICAID SERVICES 000000 0 Print this page Close Contact Us If you have a program or technical problem involving your WCMSAP submission contact the COBC EDI Department EDI Representatives can help you find solutions for any questions issues or problems you have Call the COBC EDI Department at 646 458 6740 for assistance Bulletin Board Bulletin board messages display on the WCMSAP Welcome page These messages keep users informed of upcoming events main
32. click the delete icon X to the left of the diagnosis code Diagnosis Code Add Diagnosis Code Save Work In Progress Cancel Case Creation 2 If you do not know the exact code you can search for it by clicking the Magnifying Glass icon next to Diagnosis Code Search at the top of the page The Diagnosis Codes Search page displays Rev 2011 6 December 67 WCMSAP User Manual Chapter 10 Create a New Case Diagnosis Codes Search Search for codes by entering either a partial diagnosis code in the Diagnosis Code text box or by entering descriptive keywords in the Diagnosis Keywords text box Enter at least three characters in either field You cannot search by both fields simultaneously Click the Search icon next to the field you use to find all diagnose codes that include the text or numbers entered Click the Clear button next to either field to remove any value you have entered in that box Diagnosis Codes You may search for a diagnosis code by entering a numeric value for the code or by entering any text in the text field to find all the diagnoses whose description includes that text Diagnosis Code 5933 Search 7 Search 2 Diagnosis Keywords Select Diagnosis Code Cancel After clicking Search a list of diagnosis codes displays near the bottom of the page Select the desired diagnosis code by clicking the radio button next to it then clicking the Select Diagnosis Code button Code
33. d like to Case Lookup Create a New Case Rev 2011 6 December 78 WCMSAP User Manual Chapter 11 Manage Existing Cases Case Lookup Use this page to specify which cases to display For Account Designees You must select an Account ID first if you are assigned to more than one WCMSAP account Use the fields on the page to narrow search results e Select the All Cases radio button to view submitted and Work In Progress cases assigned to you e Select the Submitted Cases Only radio button to view submitted cases assigned to you e Select the WIP Cases Only radio button to view Work In Progress cases assigned to you The remaining fields are all optional Workers Compensation Set Aside Web Portal Home About This Site CMS Links How To Reference Materials Contact Us Logoff Case Lookup Help About This Page You can access Workers Compensation Medicare Set Aside WCMSA cases that have been submitted through the Web portal and are associated with your Login ID using various search criteria Enter the search criteria in the provided fields and click Search Selecting Cancel will return you to the Home page All Cases Both submitted and WIP cases O Submitted Cases Only O WIP Cases Only Case Control Number Health Insurance Claim Number HICN OR ssn Case Creation Date Range pau m FAA gt From
34. determination regarding Medicare Secondary Payer recovery rights Medicare has both a direct recovery right and a subrogated right to recover Medicare payments related to any workers compensation WC settlement judgment award or other recovery Any payments Medicare may have made that are related to the WC settlement judgment award or other recovery must be repaid Closing Sincerely Gerald Walters Director Financial Services Group Office of Financial Management Enclosure CC CcField Rev 2011 6 December 117 WCMSAP User Manual Chapter 15 Sample WCMSAP Correspondence Zero Set Aside Letter CATS CENTERS for MEDICARE amp MEDICAID SERVICES MEDICARE Coordination of Benefits MailDate SubName RE Workers Compensation Medicare Set aside Arrangement Claimant Claimant HICN SSN HicnSSN Date of Injury InjuryDate Case Number Caseld Dear Sir or Madam This letter is in response to your initial proposal for a Workers Compensation Medicare Set aside Arrangement WCMSA received on behalf of the above named individual on SubDate You proposed that no WCMSA be established for the purpose of paying future medical services and future prescription drug expenses related to the work injury or illness that would otherwise be reimbursable by Medicare We have evaluated your proposal along with the supporting medical documentation you submitted and have determined that Medic
35. displays with the new Designee listed with the status of Active Delete Last Name First Name E mail Address Passphrase Status xX LAST FIRST AAAAAAAAAAAA AAAAAAA x LAST FIRST AAAAAAAAAAAA AAAAAAA Pending Rev 2011 6 December 51 WCMSAP User Manual Chapter 8 Designee Maintenance 11 If the entered E mail address is NOT found in the system the Designee Invitation page displays Enter the invited Designee s First Name Last Name create a Passphrase and then click Next CATS Workers Compensation Set Aside Web Portal Home About This Site CMS Links How To Reference Materials Contact Us Logoff Designee Invitation Please provide the name and a pass phrase for the designee to enter during the registration process An asterisk indicates a required field Designee First Name Designee Last Name Passphrase Re enter Passphrase When the user clicks Next they will be taken to a confirmation page stating that an invitation e mail notifying Jane Doe to register on the WCMSAP Website will be sent to the provided E Mail Address If the user clicks the Previous button they will be taken to the Designee E mail entry screen If the user clicks Cancel from the pass phrase entry screen the action will be terminated and the Designee will not be added to the account The Passphrase should be a short case sensitive phrase of your creation Enter a word or words up to 30
36. s Login ID and or password may be in violation of federal law including the False Claims Act the Computer Fraud and Abuse Act and other relevant provisions of federal civil and criminal law Violators may be subject to administrative disciplinary action and civil and criminal penalties including civil monetary penalties For site security purposes we employ software programs to monitor and identify unauthorized access unauthorized attempts to upload or change information or attempts to otherwise cause damage In the event of authorized law enforcement investigations and pursuant to any required legal process information from these sources may be used to help identify an individual and may be used for administrative criminal or other adverse action Privacy Act Statement The collection of this information is authorized by 42 U S C 1395y b 5 The information collected will be used to identify and recover past mistaken Medicare primary payments and to prevent Medicare from making mistakes in the future for those Medicare Secondary Payer situations that continue to exist Attestation of Information have submitted all relevant information obtained and or have knowledge of regarding this claimant that was generated at any time on or after the Date of Incident DOI for the alleged accidentillness injury incident at issue and has been included as part of this submission of the proposed amount for this WCMSA to the Centers for Medicare amp
37. sample notification E mail and Profile Report It may take up to 10 business days to receive the Profile Report You will have 60 business days to review sign and return the Profile Report to the COBC When returning the signed Profile Report via email use WCMSAP Profile Report in the subject line If a signed Profile Report is not received within that timeframe the account will be automatically deleted on the 60 business day If the account is deleted you must start the registration process from the beginning Refer to Chapter 4 for more information on completing the account setup Rev 2011 6 December 23 WCMSAP USER MANUAL Chapter 4 Account ID Setup amp Account Manager Registration Account Setup Corporate Account Types Upon receipt of the mailed Account ID and PIN the Account Representative AR must provide the information to the designated Account Manager AM who must then access the WCMSAP to complete the account setup process Representative Account Types Upon receipt of the mailed Account ID and PIN you can provide the information to a designated AM or assign yourself to the AM role The AM must then access the WCMSAP to complete the account setup process Self Account Types By default you will be the AM for this Account ID Once you have received the Account ID and PIN in the mail you must return to the WCMSAP site to complete the account setup process All Account Types The following s
38. system without authority or in excess of granted authority such as access through use of anothers Login ID and or password may be in violation of federal law including the False Claims Act the Computer Fraud and Abuse Act and other relevant provisions of federal civil and criminal law Violators may be subject to administrative disciplinary action and civil and criminal penalties including civil monetary penalties For site security purposes we employ software programs to monitor and identify unauthorized access unauthorized attempts to upload or change information or attempts to otherwise cause damage In the event of authorized law enforcement investigations and pursuant to any required legal process information from these sources may be used to help identify an individual and may be used for administrative criminal or other adverse action Privacy Act Statement The collection of this information is authorized by 42 U S C 1395y b 5 The information collected will be used to identify and recover past mistaken Medicare primary payments and to prevent Medicare from making mistakes in the future for those Medicare Secondary Payer situations that continue to exist Attestation of Information have submitted all relevant information obtained and or have knowledge of regarding this claimant that was generated at any time on or after the Date of Incident DOI for the alleged accidentillness injury incident at issue and has been included as p
39. the E Mail Address of a potential designee To cancel and return to the Designee Listing page click the Previous button An asterisk indicates a required field We ask for the e mail address to verify if the person is currently a registered user Designee E mail Address Re enter Designee E mail Address 5 Enter and re enter the E mail address of the Account Designee you wish to invite and click Next Or click Previous to return to the Designee Listing page without adding a Designee 6 The system then verifies that the entered E mail address is not in the database for an existing user 7 An existing registered user can be an Account Designee for your Account ID as long as they are not already registered as an Account Representative for any Account ID or the Account Manager for the same Account ID If the entered E mail address is found in system if the invited Account Designee is already a registered user the following page displays CATS Workers Compensation Set Aside Web Portal CENTERS for MEDICARE amp MEDICAID SERVICES Home About This Site CMS Links How To Reference Materials Contact Us Logoff Designee Invitation The e mail address that you entered has been found please verify this is the Designee you intended to invite If the user clicks Continue they will be taken to a confirmation page that states that the designee will receive an email notifying them that they have b
40. the proposed amount for this WCMSA to the Centers for Medicare amp Medicaid Services The information provided is complete truthful accurate and meets all requirements set forth to use this process and have read and understand all of the Centers for Medicare amp Medicaid Services information at http Wwww cms gowWorkersCompAgencySerices LOG OFF IMMEDIATELY if you do not agree to the conditions stated in this warning Accept lin 1 A Privacy Act system of records is a group of any records about individuals and under the control of any Federal agency from which information is retrieved by the name or other personal identifier of the individual Privacy Policy User Agreement 3 Review the DUA To proceed click the I Accept link at the bottom of the page You will be denied access to the WCMSAP registration process if you click Decline 4 The Designee Registration page displays Rev 2011 6 December 57 WCMSAP User Manual Chapter 9 Account Designee Registration Home About This Site CMS Links How To Reference Materials Contact Us Logoff Designee Registration You have been assigned as a Designee to the following account Corporate Name AAAAAAAAAAAA Account Manager Information FIRST LAST AAAAAAA AAAAAAAAAAAA AAAAAAAAAAAA AA HHHH EIN TIN HRT Telephone HE att Email AAAAAAAAAA To set up a Login ID for you to act as a Designee you will need the pass phrase created by the Account Manager
41. this approved WCMSA amount is received by CMS at the following address CMS c o Coordination of Benefits Contractor P O Box 33849 Detroit Michigan 48232 5849 Attention WCMSA Note If this case was submitted using the Worker s Compensation Set Aside Web Portal the final settlement document must be attached and submitted to the case using the Web Portal See the Case Documents section 25 Proposed Final Settlement Agreement or Court Order on the Web Portal case Para2 Once the funds in the WCMSA account have been exhausted and Medicare has been provided with information to document that payments from the account were appropriate Medicare will begin paying for the beneficiary s Medicare covered services that are related to the work injury or disease The beneficiary s Medicare covered expenses that are not related to the work injury or disease are not affected by the WCMSA and will be reimbursed by Medicare unless another entity under 42 U S C Section 1395y b is responsible for primary payment of such expenses Funds ina WCMSA may not be used to purchase a Medicare supplemental insurance policy or a Medigap policy for a beneficiary or to pay for the premiums for such policies Para3 Rev 2011 6 December 116 WCMSAP User Manual Chapter 15 Sample WCMSAP Correspondence Contractor Please note that decisions regarding future medical treatment and or future prescription drug expenses are independent of any
42. to Designee Maintenance Create a New Case View Account Activity Change Password Case Lookup View Alerts Rev 2011 6 December 37 WCMSAP User Manual Chapter 5 Login Forgot Login ID 1 On the Welcome page click the Forgot ID link in the Account Sign in box User Name pee Forgot ID 2 This displays the Forgot Login ID page Enter your E mail address and click Continue CATS Workers Compensation Set Aside Web Portal About This Site CMS Links How To Reference Materials Contact Us Forgot Login ID An asterisk indicates a required field Help About This Page Enter your E mail address Cancel Continue 3 The page then re displays with the two Security Questions you selected during the registration process Correctly answer each of your pre selected Security Questions then click the Continue button If the information you entered is correct your Login ID will be sent via E mail CMTS Workers Compensation Set Aside Web Portal About This Site CMS Links Reference Materials Contact Us Forgot Login ID An asterisk indicates a required field Help About This Page Security Question 1 What city were you born Answer 1 Security Question 2 What is your father s middle name Answer 2 Gara If you receive an error indicating that the answers are incorrect check your answers and re enter If
43. vendors User Name with the ability to track their submitted cases and the statuses without inquiry to the Coordination of Benefits Contractor COBC or the Centers for Medicare Forgot ID amp Medicaid Services CMS Password WCMSAP Messages Eo i ere a ic This space is reserved for system messages from the Coordination of Benefits A Contractor Check this location for important information regarding system outages scheduled maintenance and special announcements Login Clear GETTING STARTED For more information refer to How To Get Started under the How To menu option STEP 1 STEP 2 New Registration m Account Setup Account ID and PIN required 5 Click the New Registration link 6 The Select Account Type page displays This page describes the differences between each account type Corporate Account Type This submitter is registering as a corporate entity with an Employer Identification Number EIN Those registering as a Corporate account type will regularly submit WCMSAP requests Representative Account Type This submitter is a non corporate WCMSAP user This submitter does not have an EIN but will be submitting multiple cases Self Account Type This submitter is a Medicare beneficiary or a claimant who has a reasonable expectation of becoming a Medicare beneficiary within 30 months and is submitting a case on their own behalf The registrant can only submit cases for themselves Rev 2011
44. you cannot remember the answers to your Security Questions contact a COBC EDI representative Rev 2011 6 December 38 WCMSAP User Manual Chapter 5 Login 4 The Thank You page displays if your answers are correct This page confirms that you have successfully requested your Login ID CATS Workers Compensation Set Aside Web Portal Thank You You hre successily requested your Logn IO for the Workers Compensation Medcare Set Asse Ponai WCMSAP NEXT STEPS You wil recene an E mad once your Logn request s processed The E mail vell contan your Loge 10 Please note The E maili message wil be sert from a nothcation only address that cannot accept mcormng E mail Please de not reply to E you de not recane your E mail withen 24 hours please call the COBC EDI Department at 646 4586740 EDI Represantatnes are aalabie to asset you Monday through Faday excluding Federal holidays tom 900 a m to 500 pm Eastern Time Workers Compenssice Medes are Set Arde Welcome Page 5 Click the Workers Compensation Medicare Set Aside Welcome Page link to return to the Welcome page You will then receive an E mail containing your Login ID After receipt of the E mail return to the WCMSAP site and log in using your Login ID and Password If you do not receive an E mail within 24 hours contact a COBC EDI representative Forgot Password 1 On the Welcome page click the Forgot Password link in the Account Sign in box
45. A AE EE A E A ni eee ae 7 Account Loin ssy a rE A A A A e ies 7 Chapter 3 New Registration ssscssssssrssrssssressessessesessesensessensesesseseeessesessesesensesessensesseseneesesesnessessesessesessessesess 8 NCW RE QISEVCLION Li nani ninia 8 Corporate ACCOUNT PO esiiniitaiiinlr tp illa lso lidia 12 Representative Account Ty pe icici sscesssescees stash cosspestescechcbtetsncedduassqssgebavesdstsaehshsasunesige dscesscesseeaden stehstdebeodseseaseeseenaaey 16 Self ACCOUNT Peseta ii dci 20 Chapter 4 Account ID Setup amp Account Manager RegistratioN ocooommmmmssmmssss 24 Account CUP ei iia Tiida laos 24 Corporate Account Type smee ee Nava inched eee eens ered ie he Tae na eee a 28 Representative Account Type eee eecceecesscesecssecssecssecseecseeeseceaeeseeeseeesecssecsaecsaecsaecsaecseseaeseaeseeesaeeeseesseeaeenaees 29 Self Account Types nic ponia 30 Account Manager AM Self Registration cccccsccsscesseessesscesscescceseceecusecsecuaecuaecasecseeeaeeeseesaeesseeeeeeeeesseenseenaecnaeenae 31 PEO REPO adas oia 35 Chapter AAA 36 LogIn to the WOMSAP Mein A A A A Dd de 36 FOLSOt LOGUE LD A Ria e aida 38 Forgot PassWord ae ee See ede A hate ede tet Beate 39 Chapter 6 WCMSAP Home Page cssccscscssscscscssssccsscssscssscsescncsnecssccsscssscsscssscsssssssssssscsssssecsncesncesecssocsscessesssess 41 Chapter 7 Account Settings cccccscccsccssscsssccssscsssessssssessscsesesecsscessessecsseessc
46. COBC EDI Department if you do not receive a Profile Report after 10 business days You or the Account Representative will have 60 business days to review sign and return the Profile Report to the COBC When returning the signed Profile Report via email use WCMSAP Profile Report in the subject line If a signed Profile Report is not received within that timeframe the account will be automatically deleted on the 60 business day If the account is deleted you must start the registration process from the beginning Rev 2011 6 December 35 WCMSAP USER MANUAL Chapter 5 Login Log In to the WCMSAP Site 1 2 Rev 2011 6 December Enter the following URL into your Web browser https www cob cms hhs gov WCMSA The Login Warning page displays detailing the Data Use Agreement DUA CMTS Workers Compensation Medicare Set Aside Web Portal CENTERS for MEDICARE amp MEDICAID SERVICES Login Warning aaao e Print this page UNAUTHORIZED ACCESS TO THIS COMPUTER SYSTEM IS PROHIBITED BY LAW This web site is maintained by the U S Government and is protected by federal law Use of this computer system without authority or in excess of granted authority such as access through use of anothers Login ID and or password may be in violation of federal law including the False Claims Act the Computer Fraud and Abuse Act and other relevant provisions of federal civil and criminal law Violators may be subject to administ
47. E 8 MEDICAID SERVICES About This Site CMS Links How To Reference Materials Contact Us Welcome to the WCMSAP CMTS Workers Compensation Medicare Set Aside Web Portal This site provides an interface for entry of Workers Compensation Medicare GETTING STARTED For more information refer to How To Get Started under the How To menu option STEP 1 STEP 2 New Registration m gt Account Setup gt Account ID and PIN required Set Aside Arrangements WCMSA proposals Attorneys Medicare sa take beneficiaries claimants insurance carriers and WCMSA vendors may use this Sign into your account site to enter the case information directly The site also provides attorneys Medicare beneficiaries claimants insurance carriers and WCMSA vendors User Name with the ability to track their submitted cases and the statuses without inquiry to the Coordination of Benefits Contractor COBC or the Centers for Medicare Forgot ID amp Medicaid Services CMS Password WCMSAP Messages ae This space is reserved for system messages from the Coordination of Benefits Sa Contractor Check this location for important information regarding system outages scheduled maintenance and special announcements Clear Rev 2011 6 December WCMSAP User Manual Chapter 2 WCMSAP Welcome Page Navigation Menu The navigation menu at the top of each page gives the user access to various parts of the WCMSAP to facilitate using the
48. Medicare Set Aside Portal Profile Report Sample Profile Report Account ID AccountID Account Type Corporate Date 99 99 9999 COBC EDI Contact Information E mail COBVA GHIMedicare com Phone 646 458 6740 Company Information EIN HAHAHAHA AA Name AAAAAAAAAAAA Phone HHH HAHAHAHA Address AAAAAAAAAAAA AAAAAAAAAAAA AAAAAAAAAAAA St HHAHH HHEH Account Representative Name FIRST LAST Phone H HHH HHHH Title AAAAAAAAAAAA Fax HEH HHH HHHH Address AAAAAAAAAAAA AAAAAAAAAAAA AAAAAAAAAAAA St HHHHH AHHH E mail Repemail address com Account Manager Name FIRST LAST Phone F H HFHH Address AAAAAAAAAAAA AAAAAAAAAAAA AAAAAAAAAAAA St 99999 9999 E mail AMemail address com Account ID Account Type Corporate Date 99 99 9999 COBC EDI Contact Information E mail COBVA GHIMedicare com Phone 646 458 6740 Rev 2011 6 December 102 WCMSAP User Manual Chapter 15 Sample WCMSAP Correspondence SAFEGUARDING amp LIMITING ACCESS TO DATA I the undersigned Account Representative for the WCMSA corporate account defined above certify that the information contained in this Registration is true accurate and complete to the best of my knowledge and belief and I authorize CMS to verify this information I agree to establish and implement proper safeguards against unauthorized use and disclosure of the data for the purposes of WCMSA proposal s review and processing Proper safeguards s
49. NTERS for MEDICARE amp MEDICAID SERVICES Home About This Site Corporate Information Workers Compensation Set Aside Web Portal CMS Links How To Reference Materials Contact Us Logoff An asterisk indicates a required Employer Identification Numbe Corporation Business Mailing Address Address Address Zip Code Previous Next Cancel field Help About This Page r EIN Name i Line 1 Line 2 City State Select v Corporate Information Page Field Description Employer Identification Number EIN The IRS assigned employer identification number EIN associated with the organization If you have more than one EIN you may submit this registration with any one of those EINs Corporation Name Company Name Address Line 1 Enter the first line of the company s mailing address Address Line 2 Enter the second line of the company s mailing address Optional City Enter the city where the company is located State Select the state where the company is located from the dropdown list Note To quickly select a state type the first letter to scroll to the desired state Zip Code Enter the company s Zip Code Required plus 4 digit Zip code suffix Optional Command Buttons Previous Click to return to the Select Account Type page
50. Name Enter your first name MI Enter your middle initial Optional Last Name Enter your last name AR Title Enter your job title AR E mail Address Enter your E mail address Note If your E mail address is found in the system as an existing user you will NOT be allowed to continue the registration process AR Re enter E mail Address Enter your E mail address a second time for verification purposes AR Phone Enter your work phone number The Extension field is optional AR Fax Enter your work fax number Optional Command Buttons Previous Click to return to the Corporate Information page Next Click to save changes and continue to the next page Cancel Click to cancel the registration process Information entered on the current page and any previous pages is NOT saved Rev 2011 6 December 13 WCMSAP User Manual Chapter 3 New Registration 3 Enter the required information then click Next The Registration Summary page displays This page lists all the information that was previously entered All information should be reviewed and verified before continuing CATS Workers Compensation Medicare Set Aside Web Portal CENTERS for MEDICARE amp MEDICAID SERVICES About This Site CMS Links Reference Materials Contact Us Registration Summary CR E Print this page Account Type Corporate Corporate Information Account Representative Information First N FI
51. Pending Case Received Case Reopened after RO CLOS Closeout Approved Assigned Beneficiary Under Threshold Manually Closed Case Completed Deceased Case Denied unable to process case In Development WCRC Recommendation Completed at RO Development Received Case Reopened after RO COMP Under Threshold Non Bene Case No CMS Review Zero Set aside Rev 2011 6 December 81 WCMSAP User Manual Chapter 11 Manage Existing Cases Case Listing Page Field Description Note A case status of Approved means the Regional Office has approved and is working the case an Approval letter may not have been generated yet Once the Regional Office has completed their review of the case the user will receive an email alert notification and they can go to the Alerts list screen and retrieve the approval letter Location of the case Options are Case Location Submitter WCRC RO Regional Office Creation Date Date the case was created Submission Date Date the case was submitted Case Access Click the Manage Access link to grant or revoke AD access to the case AM only Command Buttons Previous Click to return to the Case Lookup page Cancel Click to return to the Home page Click the case number link for a case to display the Case Summary page Click the Manage Access link for a case to display the Manage Case Access page Rev 2011 6 December 82 WCMSAP User Man
52. Portal CMS Links How To Reference Materials Contact Us Logoff Attorney d Notes d Documents i Summay Employer Information An indicates a field required for case submission Employer Name Address Line 1 1 Address Line 2 Help About This Page 1 City State Select M Zip Code Phone Tax ID Number TIN __ Save Work In Progress CaseSummary J _CancelCase Creation Employer Information Page Field Description Employer Name Enter the employer s name Address Line 1 Enter the first line of the employer s mailing address Address Line 2 Enter the second line of the employer s mailing address Optional City Enter the city where the employer is located State Enter the state where the employer is located from the dropdown list Zip Code Enter the employer s zip code The ZIP 4 field is optional Phone Enter the employer s phone number The extension field is optional Tax ID Number TIN Enter the employer s Tax Identification Number Optional Command Buttons Previous Click to return to the WC Carrier page Next Click to save changes and continue to the next page Save Work In Progress Click to save all information entered up to this point and exit the case creation process Case Summary Click to go to the C
53. R RRHH First Name FIRST MI M Last Name LAST Corporation Name AAAAAAAAAAAA AAAAAAAA Phone HH 44 EHH ext 444 Business Mailing Address Address Line 1 AAAAAAAAAAAA Zip Code FHH AHH Review the listed information and click the Next button If any of the listed information is incorrect contact a COBC EDI representative to have it corrected Rev 2011 6 December 28 WCMSAP User Manual Chapter 4 Account ID Setup amp Account Manager Registration Representative Account Type After all information has been verified by the system the Account Setup Representative Information page displays The Representative Information page displays information entered during the initial registration process CATS Workers Compensation Medicare Set Aside Web Portal CENTERS for MEDICARE amp MEDICAID SERVICES CMS Links How To Reference Materials Contact Us About This Site Account Setup Representative Information First Name FIRST MI M Last Name LAST Phone 44 HEH HHH ext Representative Mailing Address Address Line 1 AAAAAAAAAAAA Address Line 2 AAAAAA City AAAAA State AA Zip Code HEHE HHH Review the listed information and click the Next button If any of the listed information is incorrect contact a COBC EDI representative to have it corrected Rev 2011 6 December WCMSAP User Manual Chapter 4 Account ID Setup amp Account Manager Registration
54. RSTMI M Last N LAST Employer Identification Number EIN ee kl es eer A eer Title AAAAAAAAAA Corporate Name AAAAAAAAAAAA E Mail Address AAAAAAAAAA Business Mailing Address Phone HEHEHE ext HHH Fax HH HH HHH Address Line 1 AAAAAAAAAAAA Address Line 2 AAAAAAAAAAAA City AAAAAAAAAAAA Previous Submit Registration _ Cancel 4 Verify that all information is correct To make any corrections click the Edit button next to the proper section to return to that page Once all corrections have been made click Next at the bottom of that page to navigate back to the Summary page After you have returned to the Registration Summary page click the Submit Registration button Click Previous to return to the Account Representative AR Information page If you click Cancel you will exit the registration process All information entered during the registration process is deleted After you click Submit Registration the Thank You page displays outlining the next steps in the registration process Rev 2011 6 December 14 WCMSAP User Manual Chapter 3 New Registration CMTS Workers Compensation Medicare Set Aside Web Portal CENTERS for MEDICARE amp MEDICAID SERVICES Home About This Site CMS Links How To Reference Materials Contact Us Logott Thank You A Print this page You have successfully completed the initial registration for the Workers Compensation Set Asid
55. Report via email use WCMSAP Profile Report in the subject line If a signed Profile Report is not received within that timeframe the account will be automatically deleted on the 60 business day If the account is deleted you must start the registration process from the beginning Refer to Chapter 4 for more information on completing the account setup Rev 2011 6 December 19 WCMSAP User Manual Chapter 3 New Registration Self Account Type 1 For Self account types the Beneficiary Claimant Information page displays Enter your personal information on this page The information you enter on this page is for the beneficiary or claimant associated with the case that will be created using this Account ID and the address entered will be used to send the Profile Report and any correspondence from the COBC regarding this Account ID Fields marked with an asterisk are required CENTERS for MEDICARE amp MEDICAID SERVICES CMTS Workers Compensation Medicare Set Aside Web Portal O Home About This Site CMS Links How To Reference Materials Contact Us Logoff Beneficiary Claimant Information Mailing Address An asterisk indicates a required field Health Insurance Claim Number HICN Social Security Number SSN a SSN is re q Date of Birth MM DD CCY Y E Mail Address Re enter E Mail Address Address Line 1 Address Line 2 Help About This Page Name if
56. ST Designee Email AAAAAAAAAA Rev 2011 6 December 52 WCMSAP User Manual Chapter 8 Designee Maintenance The invitation E mail will come from cobva ghimedicare com Inform your Designee to allow E mail deliveries from this address 13 Click the Return to Home button to go back to the Home page or click Next to go to the Designee Listing page 14 If you click Next the Designee Listing page re displays with the new Designee listed with the status of Pending Delete Last Name First Name E mail Address Passphrase Status RARARAS x LAST FIRST x LAST FIRST Delete a Designee 1 On the Designee Listing page click the Delete icon x next to the Designee you wish to delete from the account Delete Last Name First Name E mail Address Passphrase Status X LAST FIRST AAAAAAAAAAAA AAAAAAA Active Designee First Name Designee Last Name Desegnee Ems 3 If you do NOT want to delete the selected Designee click Cancel to return to the Designee Listing page which will show the Account Designee still listed with their status unchanged 4 If you DO want to delete the selected Designee click Continue 5 The system disassociates the Account Designee from the account and re displays the Designee Listing page without the Account Designee who was just deleted This removes the AD from this Account ID only but they will retain access to any other Account ID they are currently associated
57. Security Number E Mail Address Re enter E Mail Address Phone Fax Mailing Address Address Line 1 Address Line 2 City Help About This Page MI Last Name ext State Select M Zip Code Representative Information Page Field Description First Name Enter your first name MI Enter your middle initial Optional Last Name Enter your last name E mail Address Enter your E mail address Note If your E mail address is found in the system as an existing user you will NOT be allowed to continue the registration process Re enter E mail Address Enter your E mail address a second time for verification purposes Phone Enter your phone number The Extension field is optional Fax Enter your fax number Optional Address Line 1 Enter the first line of your mailing address Rev 2011 6 December 16 WCMSAP User Manual Chapter 3 New Registration Representative Information Page Field Description Address Line 2 Enter the second line of your mailing address Optional City Enter the city where you are located Stat Select the state where you are located from the drop down list ate Note To quickly select a state type the first letter to scroll to the d
58. TING ACCESS TO DATA I the undersigned Account Manager for the WCMSA representative account defined above certify that the information contained in this Registration is true accurate and complete to the best of my knowledge and belief and I authorize CMS to verify this information I agree to establish and implement proper safeguards against unauthorized use and disclosure of the data for the purposes of WCMSA proposal s review and processing Proper safeguards shall include the adoption of policies and procedures to ensure that the data obtained shall be used solely in accordance with Section 1106 of the Social Security Act 42 U S C 1306 Section 1874 b of the Social Security Act 42 U S C 1395k b Section 1862 b of the Social Security Act 42 U S C 1395y b and the Privacy Act of 1974 as amended Rev 2011 6 December 105 WCMSAP User Manual Chapter 15 Sample WCMSAP Correspondence 5 U S C 552a The WCMSA authorized representative shall establish appropriate administrative technical procedural and physical safeguards to protect the confidentiality of the data and to prevent unauthorized access to the data provided by the CMS I agree that the authorized representatives of the CMS shall be granted access to premises where the Medicare data are kept for the purpose of inspecting security arrangements and confirming whether the WCMSA submitter is in compliance with the security requirements specified above Access to a
59. TT E E ARE EEEE 95 Expired Pass word eneren O aE Er EE E EES E 95 Deleted Accor E Mason E O EE A T T A E a T EE 95 Case Creation EA A a EEA 95 Duplicate Case EXIStS oil 95 Case Under Threshold ion e ETI E T ra drid Suna tee 95 Cas Submission ELLOS LA 95 Invalid Diagnosis Code cio dia EEEN tuk OERE EEES EE SREE EE EKE ue CEEE EEEE ERS 95 Incomplete Case Information ntie sereoo eeen eass eeo as oaa oe EEN eS eo oa oE oE a o E eS 96 Chapter 15 Sample WCMSAP Correspondence e sessesessoesessossesocssescosoesessossesoessesoesoesessossesoossesoesseseosossessossesoesssso 97 System Generated E mails ir aaa aaa gaan ceive Sods E A A A aP EEEE aa ASETE EEE A 97 Successful Vetting Notification Corporate Account sesssesesssesessrsrreresreerssrerrnertesresrertssrerrnrestentesrenteseeersse 97 Successful Vetting Notification Representative Account sessesesessresesrtesssrsrresesresrestesrssrertnentenesreereseeerssee 98 Successful Vetting Notification Self ACCOUNL cee ceeccessseceeeecssecesneecaeceseeecsaeceneecsaeceeeecsaeceneessaeceeeeesaeeeaees 99 Post Registration Leto osas eas arrer ereere eriep s eoo E EPEE EEE ERS EE SEES EEs Poo SEESE RSET seS E EESE S EENES 100 Profile Report E mail Notification Corporate Account eseseesesesseesesreerssreerssestresrsreetssterrsresreserreetsseeeessee 101 Profile Report E mail Notification Representative Account oooocococccccconnnonnnononanonnncnnnco nono nono nooo nono no nnncnn
60. ages Forgot Password This space is reserved for system messages from the Coordination of Benefits Contractor Check this location for important information regarding system outages scheduled maintenance and special announcements GETTING STARTED For more information refer to How To Get Started under the How To menu option STEP 1 STEP 2 New Registration mm Account Setup gt Account ID and PIN required Enter your Login ID in the User Name field and your Password in the Password field and click Login The WCMSAP Home page displays This page functions as the main processing page to initiate any WCMSAP functions Refer to Chapter 6 for more information about the Home page CMTS Workers Compensation Set Aside Web Portal About This Site CMS Links How To Reference Materials Contact Us WCMSAP QUICK HELP The WCMSAP provides an interface for entry of Workers Compensation Medicare Set Aside WCMSA proposals You may use this site to enter the case information directly The site also provides the ability to track submitted cases and the statuses without inquiry to COBC or CMS Case Lookup and View Alert functions are also available Click the desired link below to perform that function Help About This Page Account Settings Update Personal Information You may modify Account Settings by clicking the appropriate link under the Account Settings list Update Account Information I d like
61. aimant2 Rev 2011 6 December 113 WCMSAP User Manual Chapter 15 Sample WCMSAP Correspondence Centers for Medicare amp Medicaid Services CMS Workers Compensation WC Medicare Set aside Proposal Requirements Checklist McDate2 Claimant3 CaseNo2 Please append only the item s indicated below no later than 10 business days from the date of this document Medical records must be submitted in a logical order If you have further questions please contact RoName3 at RoPhone3 1 A cover letter must include the following information for all Medicare Set aside arrangement proposals Section1 2 Documentation that must be available to CMS prior to the approval of a Medicare set aside arrangement Section2 FreeText Rev 2011 6 December 114 WCMSAP User Manual Chapter 15 Sample WCMSAP Correspondence SAMPLE CONSENT TO RELEASE FORM CMS Case Control Number CaseNo3 The Privacy Act of 1974 Public Law 93 579 prohibits the government from revealing information from personal files without the express written permission of the person involved Disclosure of personal records to an attorney or other representative who is acting on behalf of another person is prohibited unless the individual to whom the record pertains has consented L hereby authorize the Centers for Medicare amp Medicaid Services CMS its agents and or contractors to disclose discuss and or release orally or in
62. and AM registration Account Login After AMs and ADs have self registered and after AMs have completed the Account Setup process AMs and ADs enter their Login IDs and Passwords in the Account Login fields to enter the WCMSAP and manage the case submission process AMs can also perform AD maintenance Note AMs and ADs cannot manage or create cases until the COBC receives a valid signed copy of the Profile Report Refer to Chapter 9 for information on the AD self registration process Refer to Chapter 5 for more information about the login process including information on the Forgot Login ID and Forgot Password links on the Welcome page Rev 201 1 6 December 7 WCMSAP USER MANUAL Chapter 3 New Registration New Registration Before beginning the registration process read this entire chapter and gather all necessary information Once you have started registration you must complete the process If you click Cancel or close the application at any point before registration is complete your changes will NOT be saved and all entered data will be lost It is critical that you provide accurate information in this step Starting from the Welcome page you must provide basic information to start the registration process e For Corporate Accounts o The Employer Identification Number EIN for the company o Company name and mailing address o Account Representative AR contact information name job title address E mail address ph
63. annot be changed more than once per day Passwords cannot contain 4 consecutive characters from the previous password Passwords must be different from the last 6 Passwords Passwords cannot contain a reserved word Password welcome hcfa cms system medicare medicaid temp letmein god sex money quest 1234 or f20asya ravens redskin orioles bullets capitol Maryland terps doctor 567890 12345678 root bossman january february march april may june july august september october november december ssa firewall citic admin unisys pwd security 76543210 43210 098765 iraq ois tmg internet intranet extranet att Lockheed Rev 2011 6 December 32 WCMSAP User Manual Chapter 4 Account ID Setup amp Account Manager Registration CATS CENTERS for MEDICARE amp MEDICAID SERVICES Workers Compensation Set Aside Web Portal Home About This Site CMS Links How To Reference Materials Contact Us Logoff Account Manager Login Information The security information requested on this page will allow the system to authenticate your identity each time you log on This will ensure only you are provided the access and updating priviledges restricted to the Account Manager QUICK HELP Help About This Page Choose your Login ID and password carefully e Password must be changed every sixty 60 days Password must consist of at least eight 8 characters Password must contain at least one u
64. ant access to all ADs Check the box again to revoke access from all ADs After all changes are complete click the Continue button The Case Access Confirmation page displays listing only the ADs with access granted to the case Rev 2011 6 December 86 WCMSAP User Manual Chapter 11 Manage Existing Cases The following Designees have access to the case Designee Name FIRST LAST FIRST LAST FIRST LAST Case Listing Click the Case Listing button to return to the Case Listing page Rev 2011 6 December 87 WCMSAP USER MANUAL Chapter 12 View Alerts After cases have been submitted the WCRC reviews each case for completeness and accuracy If errors have been found in a submitted case the WCRC sends an alert E mail to the E mail address provided during account setup The alert E mail will contain the case number and the type of error found Use the Alerts section of the WCMSAP to view the alert or in most instances the letter issued by the COBC Most alerts are informational however some require action on the case Read the alert and respond if necessary Take the following steps to view alerts From the Home page click the View Alerts link in the Pd Like To box The Alert Lookup page displays I d like to Create a New Case Case Lookup View Alerts Alert Lookup By default the Alert Lookup page lists all alerts for the previous 60 days associated with the Account ID s you a
65. are s interests have been adequately considered Therefore no WCMSA is deemed necessary in this case Please note that decisions regarding future medical treatment and or future prescription drug expenses are independent of any determination regarding Medicare Secondary Payer recovery rights Medicare has both a direct recovery right and a subrogated right to recover Medicare payments related to any workers compensation WC settlement judgment award or other recovery Any payments Medicare may have made that are related to the WC settlement judgment award or other recovery must be repaid For your information in the future the Coordination of Benefits Contractor COBC should be notified of workers compensation cases involving current Medicare beneficiaries as soon as you become aware of the situation Please call the COBC at 1 800 999 1118 to report these cases and to obtain information on the coordination of any past claims for Medicare beneficiaries Please provide CMS with a copy of the workers compensation agreement once a final settlement is reached This decision regarding the WCMSA is not effective until CMS receives a copy of the final settlement The document should be mailed to the following address CMS c o Coordination of Benefits Contractor P O Box 33849 Detroit Michigan 48232 5849 Attention WCMSA Rev 2011 6 December 118 cc WCMSAP User Manual Chapter 15 Sample WCMSAP Correspondence Note If
66. art of this submission of the proposed amount for this WCMSA to the Centers for Medicare amp Medicaid Services The information provided is complete truthful accurate and meets all requirements set forth to use this process and have read and understand all of the Centers for Medicare amp Medicaid Services information at http www cms gov WorkersCompAgencySenices LOG OFF IMMEDIATELY if you do not agree to the conditions stated in this warning Accept Decline 1 A Privacy Act system of records is a group of any records about individuals and under the control of any Federal agency from which information is retrieved by the name or other personal identifier of the individual Privacy Policy User Agreement 3 Once this is displayed close your browser Rev 2011 6 December 92 WCMSAP USER MANUAL Chapter 14 Troubleshooting Replace Account Representative Use the Edit button on the Update Corporate Information page as accessed from the Account Settings box on the Home page See Chapter 7 for more information Replace Account Manager If an Account Manager must be replaced for Corporate accounts the Account Representative must contact the COBC EDI Department and request replacement AMs cannot be replaced using the WCMSAP site Unsuccessful Account Registration Previously Used EIN During initial registration an error message will display on the Corporate Information page if you enter an EIN that
67. ase the contents of that document can NOT be viewed Review the document on your system prior to uploading to ensure its accuracy To attach a document enter the file name and path in the text box or use the Browse button next to the text box to search your system for the desired document Medical records must be separated into files that contain 100 or fewer pages If a beneficiary or clatmant s medical records contain more than 100 pages create separate files before attaching the records To attach the selected file click the Attach Files button This uploads the document to the Case Documents page The file name and date the file was uploaded displays under the appropriate document category 05 Submitter Letter or Other Summary Documents Submitter Letter pdf 2010 01 20 Delete Add Replace Files Delete Files To delete a document click the Delete link that appears to the right of an already uploaded file name This permanently removes the document from the WCMSAP Note Documents can only be deleted from case that have not yet been submitted After adding all relevant documentation to the case click Next The Case Summary page displays Rev 2011 6 December 76 WCMSAP User Manual Chapter 10 Create a New Case Case Summary The Case Summary page provides a summary of all the information you have entered for the case To make any corrections click the Edit button next to the proper section to return to that secti
68. ase Summary page and view a synopsis of the case information entered Cancel Case Creation Click to delete all information entered for this case and exit the case creation process After you have entered the necessary information click Next The Beneficiary Claimant Attorney page displays Rev 2011 6 December 71 WCMSAP User Manual Chapter 10 Create a New Case Beneficiary Clai mant Attorney You have the option to enter attorney information on this page but you do not have to enter anything on this page before submitting the case However if information is entered in any field then the following fields are required Last Name First Name Address Line 1 City State Zip Code and Phone This page must be left blank if the beneficiary or claimant is not represented by an attorney CATS Workers Compensation Set Aside Web Portal CENTERS for MEDICARE 8 MEDICAID SERVICES Home About This Site CMS Links How To Reference Materials Contact Us Logoff Case Information Beneficiary Claimant Diagnosis Codes WC Carrier Employer y Attorney Notes Documents Summary Beneficiary Claimant Attorney QUICK HELP Please leave fields blank if not respresented by an attorney If any information is entered then the Help About This Page follo nf
69. ate separate files before attaching them e Payment History e Future Treatment Plans e Supplement Additional Information Document categories marked with an asterisk are required for file submission Beneficiary Claimant Diagnosis Codes WC Carrier Employer Attorney i Notes Documents Case Documents Below is a list of the documentation that is attached to this case To add documentation to the case click the Add Files link under the document type you would like to add Documents must be in PDF file Help About This Page format To delete documentation locate the document and click the Delete button that appears to the right of the file name This will permanently remove the document from the Web Portal You will not be able to delete any files that were uploaded to the WCMSA Web Portal when the case was submitted An asterisk indicates a required file 05 Submitter Letter or Other Summary Documents Add Replace Files 10 Consent Form Add Replace Files 15 Rated Age Information or Life Expectancy Add Replace Files To add a document to a case click the Add Replace Files link under the document category you would like to add This opens the Attach Documentation page Use the Attach Documentation page to browse your system and select documents to upload to the case Rev 2011 6 December 75 WCMSAP User Manual Chapter 10 Create a New Case Add Files Use the Attach Docum
70. ation at http www cms aovWorkersCompAgencyServices LOG OFF IMMEDIATELY if you do not agree to the conditions stated in this warning Accept Decline 1 A Privacy Act system of records is a group of any records about individuals and under the control of any Federal agency from which information is retrieved by the name or other personal identifier of the individual Privacy Policy User Agreement Review the DUA To proceed click the I Accept link at the bottom of the page You will be denied access to the WCMSAP site if you click I Decline The WCMSAP Welcome page displays 36 WCMSAP User Manual Chapter 5 Login CENTERS for MEDICARE amp MEDICAID SERVICES CMTS Workers Compensation Medicare Set Aside Web Portal About This Site CMS Links 2 Contact Us Welcome to the WCMSAP This site provides an interface for entry of Workers Compensation Medicare Set Aside Arrangements VWCMSA proposals Attorneys Medicare beneficiaries claimants insurance carriers and VWWCMSA vendors may use this site to enter the case information directly The site also provides attorneys Sign into your account Medicare beneficiaries claimants insurance carriers and WWCMSA vendors User Name with the ability to track their submitted cases and the statuses without inquiry to the Coordination of Benefits Contractor COBC or the Centers for Medicare Forgot ID amp Medicaid Services CMS Password WCMSAP Mess
71. ault the AM for the account For Corporate and Representative account types the AM is assigned during the Account Setup process For Representative accounts the submitter may be the AM but they have the option to assign the AM role to another person The AM e Reviews signs and returns the Profile Report upon its receipt in order to be granted full access to all WCMSAP functionality For Representative and Self account types Note For Corporate account types the AM will only be granted access after the Profile Report is signed and returned by the Account Representative AR e Manages the WCMSAP account s profile information and updates general account information e Submits new cases for the WCMSAP account they are associated with Rev 201 1 6 December 2 WCMSAP User Manual Chapter 1 Introduction e Can view and update all cases for the WCMSAP account they are associated with e Can add or replace documentation to a specific case for the account e Can invite other users to function as Account Designees AD ADs are for Corporate or Representative account types only e Can associate an AD to cases e Can revoke an AD s access to cases and or an entire WCMSAP account e Can submit a single case as an AM or as a Representative Payee For Self account types only To replace an AM the AR for Corporate accounts or the original submitter for Representative accounts must contact the COBC EDI Department Acco
72. ber 97 WCMSAP User Manual Chapter 15 Sample WCMSAP Correspondence Successful Vetting Notification Representative Account From cobva ghimedicare com mailto cobva O ghimedicare com Sent Wednesday April 01 2009 2 42 PM To AAAAA AAA COM Subject Workers Compensation Medicare Set Aside Portal WCMSAP Successful Vetting Verification Representative FIRST LAST Your information has been successfully verified and registered for the Workers Compensation Set Aside Portal WCMSAP In order to use the WCMSAP you must complete the account setup process A letter will be sent via the U S Postal Service which contains your Account Identification ID and Personal Identification Number PIN You will need this information in order to complete the final step of the account setup If you have any questions or concerns please contact our Electronic Data Interchange EDI Department Phone 646 458 6740 E mail COBVAOGHIMedicare com Confidentiality Note This electronic message transmission is intended only for the person or entity to which it is addressed and may contain information that is privileged confidential or otherwise protected from disclosure If you have received this transmission but are not the intended recipient you are hereby notified that any disclosure copying distribution or use of the contents of this information is strictly prohibited If you have received this e mail in error please contact th
73. bout This Page 47 WCMSAP User Manual Chapter 7 Account Settings Change Password Confirmation You have successfully changed your password You will be required to use the new password on your next login stemct y y q y C connue 6 Click Continue to return to the Home page Use your new Password the next time you log into the WCMSAP Rev 2011 6 December 48 WCMSAP USER MANUAL Chapter 8 Designee Maintenance For Corporate and Representative accounts the Account Manager may designate one or more Account Designees to assist with case submission and management The Account Manager can perform the following Designee Maintenance functions Add an Account Designee Delete an Account Designee Edit information for an unregistered Account Designee Regenerate an invitation E mail with a token link for an Account Designee s registration Add a Designee 1 On the Home page click the Designee Maintenance link in the Account Settings box Account Settings Update Personal Information Update Account Information Designee Maintenance View Account Activity Change Password 2 The Designee Listing page displays with all Designees and their associated statuses Pending Active Locked Expired Revoked listed CMTS Workers Compensation Set Aside Web Portal Home About This Site CMS Links How To Reference Materials Contact Us Logoff Designee Listing This page provides
74. ccanc rincon 104 Profile Report Email Notification Self Account ooooocccnoccconocononacononononaconononnnacono noo nncono noo nn conc ccoo nn conc nro nncnnnnnos 107 Alert NR A ON 110 Alert E NN 111 Below Threshold Letter Beneficiary enserrer eai e a a oan 111 Below Threshold Letter Non Beneficiary jiin iiinn i aesan a ae iiite aaia 112 Development etter cuicos E T 113 Approval Letter orinal idos 116 Zero Set Aside Tetter aiii 118 Gloseout Letonia it 120 Chapter 1 Rev 2011 6 December iv WCMSAP USER MANUAL Chapter 1 Introduction Overview The Centers for Medicare amp Medicaid Services CMS requires a mechanism to receive and evaluate future medical and future prescription drug costs for inclusion in Workers Compensation Medicare Set Aside Arrangements WCMSAs The Workers Compensation Medicare Set Aside Portal WCMSAP is a Web based application that allows attorneys beneficiaries claimants insurance carriers representative payees and WCMSA vendors to Create a work in progress case Submit WCMSA cases Perform case lookups Append documentation to a case Receive alerts relating to case activity This user guide was written to help the user understand the WCMSAP and how to complete the registration and case submission processes All implementation instructions are available on the WCMSAP dedicated Web page https www cob cms hhs gov WCMSA Account Types Before beginning the registration proces
75. characters After you complete the invitation process contact your Designee and provide them with the Passphrase They will need to enter it exactly as you did when they follow the link in their invitation E mail to register for the WCMSAP This ensures that only the people you invite will have access to your account Do not share this Passphrase with anyone else It will not be sent to the Designee in the invitation E mail You must give it to them outside the system 12 After clicking Next the Designee Confirmation page displays indicating that the invited Designee has been sent an E mail notifying them that they have been added to this Account ID and must use the token link in that E mail in addition to the Passphrase you provide them to register for the WCMSAP and access this Account ID CATS Workers Compensation Set Aside Web Portal Home About This Site CMS Links How To Reference Materials Contact Us Logoff Designee Confirmation The following Designee has been successfully added to the account The designee will receive an email notifying them that they have been invited to become a designee on the Account and may access the Account information by logging into the WCMSAP Secure Website If the invited Designee is not currently a registered user please contact the Designee and provide them with passphrase you created the passphrase is necessary for them to complete registration Designee First Name FIRST Designee Last Name LA
76. e nn IS page Account Type Self Self Beneficiary Information Mailing Address Address Line 1 AMAAAAAAAAAA First Name FIRST MI M Last Name LAST SSN HAH Address Line 2 AAAAAAAAAAAA City AAAAAAAAAAAA State AAAAAAAAAAAA HICN a A Date of Birth MONTH 4 444 Gender Male E Mail Address AAAAAAAAAAAA Phone 4 ARS Zip Code 444 HHH Previous _ SubmitRegistration _ 3 Verify that all information is correct To make any corrections click the Edit button next to the proper section to return to that page Once all corrections have been made click Next at the bottom of that page to navigate back to the Summary page After you have returned to the Registration Summary page click the Submit Registration button Click Previous to return to the Beneficiary Claimant Information page 4 After you click Submit Registration the Thank You page displays outlining the next steps in the registration process CATS Workers Compensation Medicare Set Aside Web Portal CENTERS for MEDICARE amp MEDICAJO SERVICES About This Site CMS Links How To Reference Materials Contact Us Thank You CA Print this page You have successfully completed the initial registration for the Workers Compensation Set Aside Web site Please print this page for your records Next Steps After initial registration is completed the information captured will be vetted to verify the Company Represe
77. e copying distribution or use of the contents of this information is strictly prohibited If you have received this e mail in error please contact the COBC Electronic Data Interchange EDI Department at 646 458 6740 and delete and destroy the original message and all copies TK KK Rev 2011 6 December 99 WCMSAP User Manual Chapter 15 Sample WCMSAP Correspondence Post Registration Letter current date contact name mailing address 1 mailing address 2 mail city st zip zip 4 Attn contact name Workers Compensation Medicare Set Aside Portal WCMSAP Registration Notification Your registration request has been successfully verified for the Workers Compensation Medicare Set Aside Portal Through the WCMSAP you will be able to submit cases append new documentation to a case perform case lookups and view any alerts associated with a case s To begin using the WCMSAP you must first complete the account setup process As a part of this process an account manager must be specified The Account Manager should go to the WCMSAP Web site at www WCMSAP cms hhs gov select the Account Setup button and follow the instructions presented on the screen Depending on the account type that was specified during registration note the following when selecting an Account Manager Corporate Account The Account Manager cannot be the same individual that was specified as the Account Representati
78. e COBC Electronic Data Interchange EDI Department at 646 458 6740 and delete and destroy the original message and all copies EEES Rev 2011 6 December 98 WCMSAP User Manual Chapter 15 Sample WCMSAP Correspondence Successful Vetting Notification Self Account From cobva ghimedicare com mailto cobva O ghimedicare com Sent Wednesday April 01 2009 2 42 PM To AAAAA AAA COM Subject Workers Compensation Medicare Set Aside Portal WCMSAP Successful Vetting Verification Beneficiary Claimant FIRST LAST Your information has been successfully verified and registered for the Workers Compensation Set Aside Portal WCMSAP In order to use the WCMSAP you must complete the account setup process A letter will be sent via the U S Postal Service which contains your Account Identification ID and Personal Identification Number PIN You will need this information in order to complete the final step of the account setup If you have any questions or concerns please contact our Electronic Data Interchange EDI Department Phone 646 458 6740 E mail COBVA GHIMedicare com Confidentiality Note This electronic message transmission is intended only for the person or entity to which it is addressed and may contain information that is privileged confidential or otherwise protected from disclosure If you have received this transmission but are not the intended recipient you are hereby notified that any disclosur
79. e Designee Update of Account Information Case Submitted Document Replaced Take the following steps to view account activity 1 On the Home page click the View Account Activity link in the Account Settings box Rev 2011 6 December 45 WCMSAP User Manual Chapter 7 Account Settings Account Settings Update Personal Information Update Account Information Designee Maintenance View Account Activity Change Password 2 This displays the Account Activity page CENTERS for MEDICARE amp MEDICAID SERVICES CATS Workers Compensation Set Aside Web Portal About This Site CMS Links How To Reference Materials Contact Us Account Activity Account Number 444444 Account Name AAAAAAAAAAAA Below details account activity for the Account listed Please report any discrepancies to the COB Contractor COBC Select Return Home to return to the Home Page Activity Date Activity Description User 02 15 2010 Account Registration FIRST LAST 02 20 2010 Account Setup FIRST LAST 02 20 2010 Designee Invitation FIRST LAST 3 After reviewing account activity history click the Return to Home button to go back to the Home page Rev 2011 6 December 46 WCMSAP User Manual Chapter 7 Account Settings Change Password The system requires you to change your Password every 60 days The following details the steps to successfully change your Password whether it is expired or it is a temporary Passwo
80. e Listing page displays the cases that meet the search criteria you previously entered on the Case Lookup page CATS CENTERS for MEDICARE amp MEDICAID SERVICES Home About This Site Case Listing Workers Compensation Set Aside Web Portal CMS Links How To Reference Materials Contact Us Logoff This page lists all cases entered into the Workers Compensation Medicare Set Aside Web Portal that are associated with your Login ID Click on the Case Number to view the details of the case Selecting Cancel will return you to the Home page Case Claimant Name Date of Case Case Location Creation Date Submission Case Access Number Injury Status Date 123456 LAST FIRST Sees ae ae DREC WCRC 2010 02 15 2010 02 23 Manage Access 987654 T FIRST HR ARA WIP Submitter 2010 01 24 Manage Access 798654 LAST FIRST HEHHEE E F DREC WCRC 2009 11 27 2009 12 05 Manage Access Case Listing Page Field Description The case number provided when the case was submitted or saved as a Work In Case Number p Progress Claimant Name Name of the beneficiary or claimant Date of Injury Date of initial injury Case Status WIP Submitted PEND RECD REOP CLTR APPR ASGN BUND CLOS COMP DECD DENY DEVP DISP DREC OPCM RTND ZERO Status of the case All cases have been submitted except for cases in WIP Work In Progress status Options are Work In Progress Not submitted Case submitted
81. e This Alert Close This Window A SERVIC A se e oF HEA wn Wu DEPARTMENT OF HEALTH HUMAN SERVICES Centers for Medicare amp Medicaid Services El First Last RE W Compensation Medicare Set aside Arrangement First Last f Injury e Control Number Dear First Last bmitted on Unkr rs Compensation n behalf of the al This letter Medicare in named individual must be availab ment schedule Claimant s Name First Last Date of Injury 22 2 Read the alert and review for any changes required to the account After viewing the alert click the Archive This Alert button to change the alert status to Archived Click the Close this Window button to close the alert and return to the previous page Use the case lookup process as outlined in Chapter 11 to make any necessary changes to the case Rev 2011 6 December 91 WCMSAP USER MANUAL Chapter 13 Logoff 1 From any page click the Logoff link at the top of the page IO Logoff A 2 The system ends your session and displays the Login Warning page CATS Workers Compensation Medicare Set Aside Web Portal CENTERS for MEDICARE amp MEDICAID SERVICES Login Warming oeeeeeeeeaaaaaamo E print this page UNAUTHORIZED ACCESS TO THIS COMPUTER SYSTEM IS PROHIBITED BY LAW This web site is maintained by the U S Government and is protected by federal law Use of this computer
82. e Web site Please print this page for your records Next Steps After initial registration is completed the information captured will be vetted to verify the Company Representative or Beneficiary Claimant is an appropriate submitter After the vetting has been completed the registrant will be defined with an Account identification number ID After the assignment of an Account ID a letter will be mailed to the Account Representative captured during registration with the Account ID and PIN number Account Setup Upon receipt of the mailed Account ID and PIN the Account Representative will be instructed to return to the Workers Compensation Set Aside Web site to complete the account setup The Account Manager will need to enter the Account ID and PIN on the Account Setup page to begin setup Workers Compsenation Set Aside Welcome Page 6 Click the Workers Compensation Medicare Set Aside Welcome Page link to return to the Welcome page Next Steps Within two weeks a letter will be mailed to you the AR that contains the Account ID and PIN along with instructions for setting up the account to be completed by the Account Manager Refer to Chapter 15 for a sample mailing If a letter is not received within 10 business days contact a COBC EDI representative Once the Account Manager AM has completed the account setup an E mail notification will be sent to you including a Profile Report denoting all information pre
83. e accounts only e Associates ADs to cases e Revokes AD s access to cases and or an entire WCMSAP account e Can submit new cases for the WCMSAP account they are associated with e Can view and update all cases for the WCMSAP account they are associated with e Can add or replace documentation in a specific case for the WCMSAP account they are associated with e Submits a single case for themselves or as a Representative Payee For Self accounts only Your personal information must be entered at this point to register yourself as the AM 1 After clicking Next on the applicable Information page the Account Manager Personal Information page displays The information you enter here is required for subsequent communications CENTERS for MEDICARE amp MEDICAID SERVICES CMTS Workers Compensation Set Aside Web Portal About This Site CMS Links Reference Materials Contact Us Account Manager Personal Information Please click this button if information is identical to that provided during initial registration Same as Submitter Help About This Page An asterisk indicates a required field First Name al MI Last Name E mail Address AAAAAAAAAAAA Phone i ext Mailing Address Address Line 1 Address Line 2 ciy SY You must read the User Agreement provided in the scrolling box To accept the agreement click the checkbox You mu
84. e data are kept for the purpose of inspecting security arrangements and confirming whether the WCMSA submitter is in compliance with the security requirements specified above Access to any records created by the WCMSA process shall be restricted to authorized CMS and WCMSA submitter employees agents and officials who require access to 1 perform their official duties in accordance with the approved uses of the information 2 to respond to authorized for law enforcement investigations or 3 to respond to any required legal process Such personnel shall be advised of 1 the confidential nature of the Rev 2011 6 December 108 WCMSAP User Manual Chapter 15 Sample WCMSAP Correspondence information 2 safeguards required to protect the information and 3 the administrative civil and criminal penalties for noncompliance contained in applicable Federal laws Signature of Account Manager Date Rev 2011 6 December 109 WCMSAP User Manual Chapter 15 Sample WCMSAP Correspondence Alert Email Notification From cobva ghimedicare com Sent October 01 2010 2 42 PM To All E Mail addresses associated with case Subject Alert Has Been Posted Account Number HEAR Case Control Number FAA Alert Type See values below A An Alert Type alert has been posted on the Workers Compensation Medicare Set Aside Portal This alert contains information relating to recent activity on case HHHHHHHF for account number HEHE No
85. e this URL as it contains a specific token which grants access to the registration site You will also verbally receive a Passphrase from the Account Manager which must be entered during the registration process The token link becomes inactive after 30 days of non use so it is imperative to register as soon as possible after receiving the invitation E mail As an Account Designee you register yourself on the WCMSAP using the information contained in the system generated E mail sent and the Passphrase given to you by the Account Manager You will only go through this process once as you need only one Login ID no matter how many account IDs you will ultimately work with To successfully register yourself as an Account Designee follow the steps outlined below 1 Click on the token URL provided in the invitation E mail sent by the COBC The E mail will come from cobva ghimedicare com You must allow E mail deliveries from this address 2 The Login Warning page displays detailing the Data Use Agreement DUA Rev 2011 6 December 56 WCMSAP User Manual Chapter 9 Account Designee Registration CENTERS for MEDICARE amp MEDICAID SERVICES CATS Workers Compensation Medicare Set Aside Web Portal Login Warnin Print this page UNAUTHORIZED ACCESS TO THIS COMPUTER SYSTEM IS PROHIBITED BY LAW This web site is maintained by the U S Government and is protected by federal law Use of this computer system without authority or in
86. ection details the information that must be entered by the Account Manager Contact the COBC EDI Department if you have any questions or problems regarding the Account ID at any time during account setup To successfully set up the WCMSAP account and register yourself as the Account Manager follow the steps outlined below 1 Enter the following URL into your Web browser https www cob cms hhs gov WCMSA 2 The Login Warning page displays detailing the Data Use Agreement DUA The Login Warning page may be printed by clicking the Print this Page link in the upper right of the page Rev 2011 6 December 24 WCMSAP User Manual Chapter 4 Account ID Setup amp Account Manager Registration CENTERS for MEDICARE amp MEDICAID SERVICES CATS Workers Compensation Medicare Set Aside Web Portal Login Warnin Print this page UNAUTHORIZED ACCESS TO THIS COMPUTER SYSTEM IS PROHIBITED BY LAW This web site is maintained by the U S Government and is protected by federal law Use of this computer system without authority or in excess of granted authority such as access through use of another s Login ID and or password may be in violation of federal law including the False Claims Act the Computer Fraud and Abuse Act and other relevant provisions of federal civil and criminal law Violators may be subject to administrative disciplinary action and civil and criminal penalties including civil monetary penalties For site security purposes
87. ee case aiii 67 Diagnosis Codes Search nosire r vies shee O ep edeeseaneed 68 Workers Compensation WO Carrier sins A Ai Rs Pe ee 69 Employer Inf Ova On sivas id A teks cabo a be nea A setenv Mea Re ee 71 Beneficiary Claimant AUtomney ati did cies eaten Miva beaded ive dad 72 CASEN OO A A ln 74 Case DOCUMENTS Li A a IR 75 Add mal AEA EEE poses deshh soba va srbid ouch E EEE T 76 Delete Iles EE litio so hagastetcsdaek gs shed cots seek ra sb Se shyactet stash Sedscascetisty ates vaeaveet isSesbiodees 76 Case SUMMA MA adn 77 Submit the Casetas titi eli iii aida 77 Chapter 11 Manage Existing Cases esseseesoesessessesoessesessoesessossesoesseseesosseesossesoessesoesoesessossesoessesoessessesossessossessessese 78 COSC LOOKUP criso Sa O O 79 Case LAS MB A a ide bee Bod a reese a fe 8l CASE UNMMAN A A A iw AeA E A A ewan ina Bea 83 Add Ple a iodo E E Sat eases ela 83 Replace Files A coh Sanat suse tegs a hast cesteteys E E O sings see 84 Delete Piles tina 85 Submit a Work In Progress Gaseniren a A E S A RT E AEN S N S 85 Manage Case Access innnan anna ts di E SE EE E ieee D E R Manis 86 Chapter 12 View NN 88 Alert LOOKUP S NN 88 ALCA ios 90 Alert Detail aiii AAA ita 91 AAA AN 92 O AN 92 Chapter 14 Troubleshooting scsscccscsssscsssescscssssscsscssccssscssscnecsscesscesecescesscssscssscsssssssscsssesesenecsseessessecssesssesssess 93 Replace ACCOUNT Representative sirsie sesscssvevesiasesastiasssaestiaacscaeugeusesisncsecpidg
88. een invited to become a designee on the Account and may access the Account information by logging into the WCMSAP Secure Website When they click Next they will be taken back to the Designee Listing Screen 8 If the information you entered is for the Designee you intended to invite click Next to Continue Otherwise click Cancel The Designee Confirmation page displays indicating that the invited Designee has been sent an E mail notifying them that they have been added to this Account ID and will be able to access it the next time they log in to the WCMSAP Rev 2011 6 December 50 WCMSAP User Manual Chapter 8 Designee Maintenance Home About This Site CMS Links How To Reference Materials Contact Us Designee Confirmation The following Designee has been successfully added to the account The designee will receive an email notifying them that they have been invited to become a designee on the Account and may access the Account information by logging into the WCMSAP Secure Website If the invited Designee is not currently a registered user please contact the Designee and provide them with passphrase you created the passphrase is necessary for them to complete registration Designee First Name FIRST Designee Last Name LAST Designee Email AAAAAAAAAA 9 Click the Return to Home button to go back to the Home page or click Next to go to the Designee Listing page 10 If you click Next the Designee Listing page re
89. entation page to select documents to add to a case Selected documents must be in PDF format and cannot exceed 40 MB total size for up to 3 files Files with a non PDF extension or greater than 40 MB will not be accepted The system accepts single PDF files Please do not upload files in PDF Portfolio format A PDF Portfolio contains multiple files assembled into an integrated PDF unit The document category displays near the top of the page i e Consent Form Life Care Plan If you have selected the wrong document category click the Cancel button return to the Case Documents page and click the Add Replace Files link under the desired document category CATS Workers Compensation Medicare Set Aside Web Portal O CENTERS for MEDICARE amp MEDICAID SERVICES About This Site CMS Links o Reference Materials Contact Us Logoff Attach Documentation Document Category 10 Consent Form Please type in the file name or click browse to find the file The file must be in PDF format and the size limit is 40 MB megabyte per file for attachments Note If you wish to attach multiple files with the same name lease attach them one at a time to ensure all files are attached properly The system expects single PDF files lease do not upload files in PDF Portfolio format A PDF Portfolio contains multiple files assembled into an integrated PDF unit _Browse _ Browse Attach Files Cancel Note Once documents are added to a c
90. entative to confirm the Account ID PIN combination or to unlock the PIN Rev 2011 6 December 93 WCMSAP User Manual Chapter 14 Troubleshooting Account ID Already Registered During Account Setup an error message will display on the Account Setup page if you enter an Account ID and PIN that has already successfully completed the setup process The message will indicate that the account is already setup Because the account is already setup you cannot self register as the Account Manager for the Account ID or repeat the Account Setup process There can be only one Account Manager for each Account ID If you had previously completed Account Setup for the Account ID and registered as the Account Manager go back to the Welcome page and enter your Login ID and Password to sign in to the WCMSAP site If you are not the Account Manager contact the existing Account Manager to add you as an Account Designee if you need access to the system Account Manager and Account Representative E mail Addresses Match An error message will display if during Account Setup and Account Manager self registration it is found that your E mail address as the AM matches the E mail address of any Account Representative recorded in the system Account Representatives can NOT be users of the WCMSAP site for any Account ID Click Next on the error message to be returned to the Welcome page If the wrong individual was named as the Account Representative in the New Re
91. er 69 WCMSAP User Manual Chapter 10 Create a New Case Workers Compensation WC Carrier Page Field Description Tax ID Number TIN Enter the carrier s Tax Identification Number Optional Rx PCN Enter the carriers Pharmacy Benefit Processor Control Number Optional Rx BIN Enter the carrier s Pharmacy Benefit International Identification Number Optional Command Buttons Previous Click to return to the Diagnosis Codes page Next Click to save changes and continue to the next page Save Work In Progress Click to save all information entered up to this point and exit the case creation process Case Summary Click to go to the Case Summary page and view a synopsis of the case information entered Cancel Case Creation Click to delete all information entered for this case and exit the case creation process After you have entered the necessary information click Next The Employer Information page displays Rev 2011 6 December 70 WCMSAP User Manual Chapter 10 Create a New Case Employer Information Enter the beneficiary or claimant s employer information on this page Fields marked with a superscript 1 are required Home 1s CENTERS for MEDICARE amp MEDICAID SERVICES About This Site Case Information Beneficiary Claimant Diagnosis Codes WCCarrier Employer d Workers Compensation Set Aside Web
92. er account on the sociated to multiple accounts New Contact Us Logoff Help About This Page be allowed to continue the account setup process Account Setup Page Field Description Account ID Enter the Account ID listed on the letter received from the COBC Personal Identification Enter the PIN listed on the letter received from the COBC Number PIN Enter your E mail address E mail Address Note If your E mail address is found in the system as an existing user you will NOT Re enter E mail Address Enter your E mail address a second time for verification purposes Command Buttons Previous Click to return to the Account Setup Intro page Next Click to save changes and continue to the next page 9 Enter the required information then click the Next button Rev 2011 6 December 27 WCMSAP User Manual Chapter 4 Account ID Setup amp Account Manager Registration Corporate Account Type After all information has been verified by the system the Account Setup Company Information page displays The Company Information page displays information entered during the initial registration process CMTS Workers Compensation Set Aside Web Portal Home About This Site CMS Links How To Reference Materials Contact Us Logoff Account Setup Company Information Corporate Information Account Representative Information Employer Identification Number EIN AR
93. er the assignment of an Account ID a letter will be mailed to the Account Representative captured during registration with the Account ID and PIN number Account Setup Upon receipt of the mailed Account ID and PIN the Account Representative will be instructed to return to the Workers Compensation Set Aside Web site to complete the account setup The Account Manager will need to enter the Account ID and PIN on the Account Setup page to begin setup Workers Compsenation Set Aside Welcome Page 6 Click the Workers Compensation Medicare Set Aside Welcome Page link to return to the Welcome page Next Steps Within two weeks a letter will be mailed to you that contains the Account ID and PIN along with instructions for setting up the account to be completed by the AM Refer to Chapter 15 for a sample mailing If a letter is not received within 10 business days contact a COBC EDI representative Once you have completed the account setup an E mail notification will be sent to you including a Profile Report denoting all information previously recorded during registration and any additional information provided during the account setup Refer to Chapter 15 for a sample notification E mail and Profile Report It may take up to 10 business days to receive the Profile Report You will have 60 business days to review sign and return the Profile Report to the COBC who is listed on the report When returning the signed Profile
94. esired state Zip Code Enter your Zip Code Required plus 4 digit Zip code suffix Optional Command Buttons Previous Click to return to the Select Account Type page Next Click to save changes and continue to the next page Cancel Click to cancel the registration process Information entered on the current page and any previous pages is NOT saved 2 Enter the required information then click the Next button The Beneficiary Information page displays Enter information on this page for a beneficiary associated with the case s that will be created using this Account ID Fields marked with an asterisk are required CATS CENTERS for MEDICARE amp MEDICAID SERVICES Workers Compensation Set Aside Web Portal Home About This Site CMS Links How To Reference Materials Contact Us Logott Beneficiary Information An asterisk indicates a required field Help About This Page Bene Last Name First Initial Bene Health Insurance Claim Number HICN OR Bene Social Security Number SSN SSN is required if HICN is not provided Bene Date of Birth MM DD CCYY Bene Gender Select Beneficiary Information Page Field Description Bene Last Name Enter the beneficiary s last name First Initial Enter the beneficiary s first initial Enter the beneficiary s HICN
95. essfully saved Case Number 234578 as a work in progress WIP You can return to the WCMSAP at a later time and finish creating the case then submit the case by using the case lookup process and utilizing the case number provided on the Work In Progress page See the next chapter for more information on the case lookup process If you click the Cancel Case Creation button the case will NOT be saved Cancelling the case deletes any entered information from the WCMSAP you must start the case creation process from the beginning for that case Take the following steps to successfully create a new case From the Home page click the Create a New Case link in the I d Like To box The New Case Creation page displays Rev 2011 6 December 62 WCMSAP User Manual Chapter 10 Create a New Case I d like to Create a New Case Case Lookup View Alerts New Case Creation Use the New Case Creation page to enter information for the beneficiary or claimant and to verify that the case meets all new case requirements Fields marked with an asterisk are required For Account Designees The system will first require you to select the desired WCMSAP account from the Account Listing page prior to creating a new case If any of the following conditions are found a case can NOT be created for this beneficiary or claimant
96. ev 2011 6 December 33 WCMSAP User Manual Chapter 4 Account ID Setup amp Account Manager Registration Workers Compensation Set Aside Web Portal Home About This Site CMS Links How To Reference Materials Contact Us Logoff Account Manager Summary Print this page Ie Please review your personal and login Information If you need to change the information click the Edit button If you are satisfied with the information click the Continue button to submit your information Click Cancel to cancel the setup process all data will be lost Print this page for your records Personal Information Login ID First Name FIRST MI M Last Name LAST Login ID AA123bb E Mail Address AAAAAAAAAAAA Phone HH HH HHH ext HHH Mailing Address Address Line 1 AMAAAAAAAAAA Address Line 2 AAAAAAAAAAAA City AAAAAAAAAAAA State AAAAAAAAAAAA Zip Code HHH HHH Previous Submit Account Setup Cancel 5 Verify that all information is correct To make any corrections click the Edit button next to the proper section to return to that section Once all corrections have been made click Next at the bottom of that page to navigate back to the Summary page After you have returned to the Account Manager Summary page click the Submit Account Setup button Click Previous to return to the Account Manager Login Information page 6 After you click Submit the Thank You page displays outlining the next s
97. eviously entered City Enter the city where the beneficiary or claimant lives This field is pre populated for Self Account types State of Residence Select the state where the beneficiary or claimant lives from the dropdown list This field is pre populated for Self account types Zip Code Enter the beneficiary or claimant s zip code The ZIP 4 field is optional This field is pre populated for Self account types Phone Enter the beneficiary or claimant s telephone number The extension field is optional This field is pre populated for Self account types State where injury Select the state where the beneficiary or claimant s first injury occurred from the occurred dropdown list Submitter Type Select a submitter type from the dropdown list This field is not displayed for Self account types Options are Beneficiary Claimant Representative Claimant Attorney Defendant Attorney WC Carrier Employer Medical Consultant Other Command Buttons Click to save changes and continue to the next page Save Work In Progress Click to save all information entered up to this point and exit the case creation process Click to go to the Case Summary page and view a synopsis of the case information entered Cancel Case Creation Click to delete all information entered for this case and exit the case creation process Enter the required information then click Next The Diagnosis Codes page displays Rev 2011 6 December 66 WCMSAP
98. for system messages from the Coordination of Benefits A Contractor Check this location for important information regarding system outages scheduled maintenance and special announcements Login Clear GETTING STARTED For more information refer to How To Get Started under the How To menu option STEP 1 STEP 2 New Registration m gt Account Setup gt Account ID and PIN required 5 Click the Account Setup button 6 The Account Setup Introduction page displays This page describes what steps you will be taking in the account setup process and informs you of your duties as the Account Manager CMTS Workers Compensation Set Aside Web Portal Home About This Site CMS Links How To Reference Materials Contact Us Logoff Account Setup Intro You have selected a link that guides you through the process of establishing a new Account Manager ID for the Workers Compensation Set Aside Web Portal WCMSAP Please have your Account Dentification Number EIN and Personal Identification Number PIN available The Account ID and PIN are listed on the mailing that was sent to your submitter contact If you are already associated with a Submitter on the WCMSA Web Portal you will not be allowed to register for a different Submitter An Account Manager is only allowed to be associated with one Submitter During this process you will be e Establishing an account for the Submitter and e Establishing your perso
99. g Address Address Line 1 AAAAAAAAAA Address Line 2 AAAAAAAAAAAA City AAAAAAAA AAA State AAAAAAAAAAAA Zip Code 444 11 The Thank You page displays Click the Workers Compensation Medicare Set Aside Welcome Page link to go to the WCMSAP Welcome page to log in to the site and manage account information CATS Workers Compensation Medicare Set Aside Web Portal CENTERS for MEDICARE amp MEDICAID SERVICES About This Site CMS Links How To Reference Materials Contact Us Thank You CR E Print this page You have successfully completed registration for the Workers Compensation Set Aside Web site and established yourself as a Designee for the Account ID Please print this page for your records Next Steps You may now return to the Workers Compensation Set Aside Web site welcome page login using the Login ID and Password you just created to access accounts associated with your ID You can visit the Workers Compensation Medicare Set Aside Welcome page at https Awww cob cms hhs govWCMSA You have successfully completed self registration on the WCMSAP site Rev 2011 6 December 61 WCMSAP USER MANUAL Chapter 10 Create a New Case Case Creation Overview Use the case creation process to input Workers Compensation Medicare Set Aside case information and all relevant documentation Before you begin read this chapter in its entirety and gather all required information Once a case ha
100. gistration step contact a COBC EDI representative to make the necessary correction Unsuccessful Account Designee Invitation Account Designee E mail Address Matches Account Representative or Account Manager E mail Address An error message will display if while an Account Manager is adding an Account Designee to an Account ID it is found that the Designee s E mail address matches the E mail address of any Account Representative or Account Manager recorded in the system Account Representatives can NOT be users of the WCMSAP site for any Account ID and Account Managers cannot also be Designees Click Next on the error message to be returned to the Welcome page Account Designee E mail Address Matches Account Designee Already Associated with the Account An error message will display if while an Account Manager is adding an Account Designee to an Account ID it is found that the Designee s E mail address matches the E mail address of an Account Designee already assigned to the same Account ID Return to the Designee Listing page to manage the AD s case access Unsuccessful Account Designee Registration Incorrect Passphrase The Passphrase must be provided to you the AD by the Account Manager outside the system It will not be included in the invitation E mail The Account Manager s name is contained in the invitation E mail and can also be found on the registration page where the error is received Contact your Account Manager t
101. hall include the adoption of policies and procedures to ensure that the data obtained shall be used solely in accordance with Section 1106 of the Social Security Act 42 U S C 1306 Section 1874 b of the Social Security Act 42 U S C 1395k b Section 1862 b of the Social Security Act 42 U S C 1395y b and the Privacy Act of 1974 as amended 5 U S C 552a The WCMSA Account Representative shall establish appropriate administrative technical procedural and physical safeguards to protect the confidentiality of the data and to prevent unauthorized access to the data provided by the CMS I agree that the authorized representatives of the CMS shall be granted access to premises where the Medicare data are kept for the purpose of inspecting security arrangements and confirming whether the WCMSA submitter is in compliance with the security requirements specified above Access to any records created by the WCMSA process shall be restricted to authorized CMS and WCMSA submitter employees agents and officials who require access to 1 perform their official duties in accordance with the approved uses of the information 2 to respond to authorized for law enforcement investigations or 3 to respond to any required legal process Such personnel shall be advised of 1 the confidential nature of the information 2 safeguards required to protect the information and 3 the administrative civil and criminal penalties for noncompliance conta
102. has already successfully completed the registration process for Corporate account types Change the EIN entered and continue the registration process Previously Used SSN During initial registration an error message will display on the Representative Information or Beneficiary Claimant Information page if you enter an SSN that has already successfully completed the registration process for Representative or Self account types If you have incorrectly entered your SSN on this page change the SSN entered and continue the registration process Registration Denied During initial registration an error message will display if a beneficiary entered for Representative or Self account types is not found in the database Registration cannot be completed for this beneficiary Unsuccessful Account Setup Account PIN Error The Personal Identification Number PIN for the Account ID will be sent to you for Representative or Self accounts or the Account Representative for Corporate accounts after the New Registration step has been completed If during Account Setup the Account Manager receives an Invalid Account ID PIN Combination error message check the numbers on the mailing received An Account ID should always contain nine digits and a PIN should have four digits If your numbers are shorter add leading zeros to make them the proper length You have three tries to enter the PIN correctly before the account is locked Contact a COBC EDI repres
103. he Designee Listing page click the Previous button An asterisk indicates a required field We ask for the e mail address to verify if the person is currently a registered user First Name FIRST Last Name LAST E mail Address AAAAAAAAAA Re enter E mail Address AAAAAAAAAA Passphrase BBBBBBB Re enter Passphrase BBBBBBB Y Regenerate token Check this box if another invitation email must be sent to the Designee 3 Check the Regenerate token checkbox beneath the Designee s personal information then click Next 4 The Designee Listing page re displays with the Designee s information unchanged However the system re generates the invitation E mail and sends it to the E mail Address registered for the Account Designee Rev 2011 6 December 55 WCMSAP USER MANUAL Chapter 9 Account Designee Registration Account Designees ADs are optional users associated with an Account ID who assist the Account Manager in managing a Corporate or Representative account As a Designee you will be able to perform most of the functions on the site including submitting cases but will not be able to invite additional users to be associated with the Account ID or company information ADs are assigned by the Account Manager After the AM adds you to an account the system sends you an invitation E mail containing a specific URL It is necessary for you to us
104. he proposed settlement amount for the case Command Buttons Cancel Click to return to the Select Welcome page The information entered on this page will NOT be saved Continue Click to save changes and continue to the next page Enter the required information then click Continue If the case meets minimum requirements the Beneficiary Claimant Information page displays Rev 2011 6 December 64 WCMSAP User Manual Chapter 10 Create a New Case Beneficiary Claimant Information Enter the beneficiary or claimant s contact and injury information on this page Fields marked with a superscript 1 are required CMTS Workers Compensation Set Aside Web Portal CENTERS for MEDICARE 8 MEDICAID SERVICES Home About This Site CMS Links How To Reference Materials Contact Us Logoff Case Information Beneficiary Ciaimant Diagnosis Codes Wocarrier Employer Attorney Notes Documents Summary _ Beneficiary Claimant Information QUICK HELP An indicates a field required for case submission Help About This Page Last Name FIRST First Name LAST Ml M Beneficiary HICN RRA Beneficiary Claimant SSN Beneficiary Claimant Date of Birth MM DD CCY Y Beneficiary Claimant Gender Male Address Line 1 Address Line 2 City State of Residence
105. igned by the account manager and returned to the COBC Please send signed reports to via Fax 646 458 6761 via E mail COB V A GHIMedicare com via mail MEDICARE COB Section Reporting Program P O Box 660 New York NY 10274 0660 If the report is incorrect please contact our Electronic Data Interchange EDI Department at the number or e mail address listed below to resolve any error Phone 646 458 6740 E mail COBVA GHIMedicare com Confidentiality Note This electronic message transmission is intended only for the person or entity to which it is addressed and may contain information that is privileged confidential or otherwise protected from disclosure If you have received this transmission but are not the intended recipient you are hereby notified that any disclosure copying distribution or use of the contents of this information is strictly prohibited If you have received this e mail in error please contact the COBC Electronic Data Interchange EDI Department at 646 458 6740 and delete and destroy the original message and all copies TK KK Rev 2011 6 December 107 WCMSAP User Manual Chapter 15 Sample WCMSAP Correspondence Sample Profile Report Workers Compensation Medicare Set Aside Portal Profile Report Account ID Account Type Self Date 99 99 9999 COBC EDI Contact Information E mail COBVA GHIMedicare com Phone 646 458 6740 Beneficiary Claimant Name FIRST LAST Phone
106. in this warning Accept lin 1 A Privacy Act system of records is a group of any records about individuals and under the control of any Federal agency from which information is retrieved by the name or other personal identifier of the individual Privacy Policy User Agreement 3 Review the DUA To proceed click the Accept link at the bottom of the page You will be denied access to the WCMSAP site if you click I Decline 4 The Welcome page displays Rev 2011 6 December 25 WCMSAP User Manual Chapter 4 Account ID Setup amp Account Manager Registration CENTERS for MEDICARE amp MEDICAID SERVICES CATS Workers Compensation Medicare Set Aside Web Portal About This Site CMS Links Reference Materials Contact Us Welcome to the WCMSAP This site provides an interface for entry of Workers Compensation Medicare Set Aside Arrangements WCMSA proposals Attorneys Medicare beneficiaries claimants insurance carriers and VWWCMSA vendors may use this site to enter the case information directly The site also provides attorneys Sign into your account Medicare beneficiaries claimants insurance carriers and WCMSA vendors User Name with the ability to track their submitted cases and the statuses without inquiry to the Coordination of Benefits Contractor COBC or the Centers for Medicare Forgot ID amp Medicaid Services CMS Password WCMSAP Messages a Forgot Password This space is reserved
107. ined in applicable Federal laws Signature of Account Representative Date Rev 2011 6 December 103 WCMSAP User Manual Chapter 15 Sample WCMSAP Correspondence Profile Report E mail Notification Representative Account From cobva ghimedicare com mailto cobva O ghimedicare com Sent Wednesday April 01 2009 2 42 PM To AAAAA AAA COM Subject Workers Compensation Medicare Set Aside Portal WCMSAP Profile Report Representative FIRST LAST Account Manager FIRST LAST The WCMSAP Profile Report has been attached to this e mail The Profile Report contains information regarding the representative for the account and the associated account manager information A Profile Report is generated after the account setup has been completed successfully Please review the attached Profile Report carefully and ensure all information is accurate In order to access all of the functions within the WCMSAP the report must be signed by the Account Manager and returned to the COBC Please send signed reports to via Fax 646 458 6761 via Email COB V A GHIMedicare com via mail MEDICARE COB Section Reporting Program P O Box 660 New York NY 10274 0660 If the report is incorrect please contact our Electronic Data Interchange EDI department at the number or e mail address listed below to resolve any error Phone 646 458 6740 E mail COBVA GHIMedicare com Confidentiality Note This electronic message transm
108. ing that approval of a Workers Compensation Medicare Set aside Arrangement is unnecessary when a WC settlement is 250 000 or less and the injured individual does not have a reasonable expectation of becoming a Medicare beneficiary within 30 months of the settlement date as represented by the facts in this case Please refer to the following CMS memorandums for additional information WC Commutation of Future Benefits dated July 23 2001 http www cms hhs gov medicare cob pdf wcfuturebene pdf Medicare Secondary Payer WC Frequently Asked Questions dated April 21 2003 http www cms hhs gov medicare cob pdf wc_faqs pdf Medicare Secondary Payer WC Additional Frequently Asked Questions dated May 23 2003 http www cms hhs gov medicare cob pdf wc_faqs2 pdf CMS will honor threshold levels that are in effect as of the date of the WC settlement Due to resource constraints CMS is not providing a review of this case since the facts represented do not meet the thresholds stated in the frequently asked questions documents If you have further questions please contact RoName at RoPhone Sincerely PoName cc CcFields Rev 2011 6 December 112 WCMSAP User Manual Chapter 15 Sample WCMSAP Correspondence Development Letter CATS CENTERS for MEDICARE amp MEDICAID SERVICES MEDICARE Coordination of Benefits 1 800 999 1118 or TTY TDD 1 800 318 8782 McDate WCS10094 DEVCC R 509 MailTo
109. ission is intended only for the person or entity to which it is addressed and may contain information that is privileged confidential or otherwise protected from disclosure If you have received this transmission but are not the intended recipient you are hereby notified that any disclosure copying distribution or use of the contents of this information is strictly prohibited If you have received this e mail in error please contact the COBC Electronic Data Interchange EDI Department at 646 458 6740 and delete and destroy the original message and all copies TK ak Rev 2011 6 December 104 WCMSAP User Manual Chapter 15 Sample WCMSAP Correspondence Workers Compensation Medicare Set Aside Portal Profile Report Sample Profile Report Account ID Account Type Representative Date 99 99 9999 COBC EDI Contact Information E mail COBVA GHIMedicare com Phone 646 458 6740 Representative Name FIRST LAST Phone HH F HH HFHH Title AAAAAAAAAAAA Fax AHH HHH HHHH Address AAAAAAAAAAAA AAAAAAAAAAAA AAAAAAAAAAAA St 99999 9999 E mail AcctRepemail address com Account Manager Name FIRST LAST Phone F FH HFHH Title AAAAAAAAAAAA Address AAAAAAAAAAAA AAAAAAAAAAAA AAAAAAAAAAAA St HHEHH HHEFE Email AMemail address com Account ID Account Type Representative Date 99 99 9999 COBC EDI Contact Information Email COBVA GHIMedicare com Phone 646 458 6740 SAFEGUARDING amp LIMI
110. l Address Passphrase Status X LAST FIRST AAAAAAAAAAAA BBBBBEB Pending Rev 2011 6 December 54 WCMSAP User Manual Chapter 8 Designee Maintenance Regenerate Invitation E mail When the Account Manager invites a person to be an Account Designee an E mail is generated and sent to the intended Designee informing them of the invitation and includes a token link for them to access the WCMSAP site and self register as an AD If the intended Designee has misplaced or deleted the invitation E mail or if the Designee has not registered within 30 days the Account Manager can regenerate the invitation E mail allowing the intended AD to self register The previously generated token link will not work once a new E mail is generated Invitation E mails can only be regenerated for Designees in Pending status The E mail will come from cobva ghimedicare com Inform your Designee to allow E mail deliveries from this address 1 On the Designee Listing page click the last name of the preferred Designee Delete Last Name First Name E mail Address Passphrase Status x LAST FIRST AAAAAAAAAAAA BBBBBBB Pending 2 The Update Designee Information page displays with the Designee s personal information open for editing Home About This Site CMS Links How To Reference Materials Contact Us Logoff Update Designee Information Please click the Next button to check the E Mail Address of a potential designee To cancel and return to t
111. nal Login ID to the Workers Compensation Set Aside Web Portal WCMSAP Before proceeding it is important to understand the roles of the various WCMSAP users and their respective responsibilities to ensure the Submitter accounts are managed correctly The role of the Account Manager and is described below 7 Read the introduction then click Next to continue with the account setup process 8 The Account Setup page displays Enter the Account ID and PIN You must also enter your E mail address All fields are required Rev 2011 6 December 26 WCMSAP User Manual Chapter 4 Account ID Setup amp Account Manager Registration Note If the E mail address you enter here is found in the system you will be prohibited from continuing the account setup process Account Setup sent to the account contact after completion of the New Registration step We also ask for your E mail addre SA Web Portal Existing u ss to see if you are already s will not be allowed to be a users must go through the process of creating a Login ID and Password An asterisk indicates a required field Account ID Personal Identification Number PIN Account Manager s E Mail Address Re enter E Mail Address About This Site CMS Links Reference Materials Please enter your Account Identification Number Account ID and Personal Identification Number PIN sociated to anoth
112. note in the textbox provided and click the Add Note button The note length is imited to 800 characters including spaces To delete a note click the Delete icon Notes may only be added or deleted prior to case submission Help About This Page Add Note Save Work In Progress Case Summary Cancel Case Creation The note will then display at the bottom of the page with the date it was added to the case the name of the user who added it and the content of the note Delete Date Added User Notes x 2010 01 10 FIR ST LAST Collecting documentation saving as work in progress case Save Work In Progress Case Summary Cancel Case Creation Click the Delete icon x next to a note to remove it from a case After managing any case notes click Next The Case Documents page displays Rev 2011 6 December 74 WCMSAP User Manual Chapter 10 Create a New Case Case Documents Use this page to add documents to a case or delete any existing documents on a case Documents can be added to a case under the following document categories Submitter Letter or Other Summary Documents Consent Form Rated Age Information or Life Expectancy Life Care Plan Proposed Final Settlement Agreement or Court Order Set Aside Administrator or Copy of Agreement Medical Records 1 Report of Injury through Recent Treatment Medical records must be separated into files that contain less than 100 pages Cre
113. ntative or Beneficiary Claimant is an appropriate submitter After the vetting has been completed the registrant will be defined with an Account identification number ID After the assignment of an Account ID a letter will be mailed to the Account Representative captured during registration with the Account ID and PIN number Account Setup Upon receipt of the mailed Account ID and PIN the Account Representative will be instructed to return to the Workers Compensation Set Aside Web site to complete the account setup The Account Manager will need to enter the Account ID and PIN on the Account Setup page to begin setup Workers Compsenation Set Aside Welcome Page Rev 2011 6 December 22 WCMSAP User Manual Chapter 3 New Registration 5 Click the Workers Compensation Medicare Set Aside Welcome Page link to return to the Welcome page Next Steps Within two weeks a letter will be mailed to you that contains the Account ID and PIN along with instructions for setting up the account to be completed by the Account Manager Refer to Chapter 15 for a sample mailing If a letter is not received within 10 business days contact a COBC EDI representative Once you have completed the account setup an E mail notification will be sent to you including a Profile Report denoting all information previously recorded during registration and any additional information provided during the account setup Refer to Chapter 15 for a
114. ny records created by the WCMSA process shall be restricted to authorized CMS and WCMSA submitter employees agents and officials who require access to 1 perform their official duties in accordance with the approved uses of the information 2 to respond to authorized for law enforcement investigations or 3 to respond to any required legal process Such personnel shall be advised of 1 the confidential nature of the information 2 safeguards required to protect the information and 3 the administrative civil and criminal penalties for noncompliance contained in applicable Federal laws Signature of Account Manager Date Rev 2011 6 December 106 WCMSAP User Manual Chapter 15 Sample WCMSAP Correspondence Profile Report Email Notification Self Account From cobva ghimedicare com mailto cobva ghimedicare com Sent Wednesday April 01 2009 2 42 PM To AAAAA AAA COM Subject Workers Compensation Medicare Set Aside Portal WCMSAP Profile Report Account Manager FIRST LAST The WCMSAP Profile Report has been attached to this e mail The Profile Report contains information regarding your WCMSAP account and the associated beneficiary claimant information A Profile Report is generated after the account setup has been completed successfully Please review the attached Profile Report carefully and ensure all information is accurate In order to access all of the functions within the WCMSAP the report must be s
115. o obtain the Passphrase If your Account Manager does not remember the Passphrase they can log into the WCMSAP site and create another Passphrase by accessing the Designee Maintenance page and selecting the details Rev 2011 6 December 94 WCMSAP User Manual Chapter 14 Troubleshooting associated with your last name They can then provide the correct Passphrase to you The Passphrase is case sensitive Unsuccessful Login Invalid Login ID Refer to Chapter 5 Inactive Login ID If you receive this error message at login your access to the WCMSAP site has been deactivated due to inactivity in the last 180 days Contact a COBC EDI representative to reactivate your Login ID and create a new Password Revoked Login ID If you receive this error message at login you can no longer access the WCMSAP site Invalid Password Refer to Chapter 5 Expired Password Refer to Chapter 7 Deleted Account If you receive this error message at login your account s Account ID has been deleted It has been deleted because a signed Profile Report has not yet been received by the COBC and 61 business days have elapsed from the date the Profile Report was sent Your account must go through the Registration and Setup processes again to gain access to the WCMSAP site Case Creation Errors Duplicate Case Exists If you receive this error message the system has found that a duplicate case already exists and you will not be allowed to create
116. ogress Click to save all information entered up to this point and exit the case creation process Case Summary Click to go to the Case Summary page and view a synopsis of the case information entered Cancel Case Creation Click to delete all information entered for this case and exit the case creation process After you have entered any necessary information click Next to display the Case Notes page Rev 2011 6 December 73 WCMSAP User Manual Chapter 10 Create a New Case Case Notes The Case Notes page is also optional Notes can be added to a new case at any time prior to its submission to a case saved as a Work In Progress WIP at any time prior to its submission to a submitted case when a document is replaced to a submitted case when additional documents are added Add a note to a new or WIP case to record any pertinent information Notes can only be added to submitted cases when a document is added or replaced See page 84 for more information about adding notes to submitted cases For new WIP cases enter any relevant notes in the text box then click the Add Note button CMTS Workers Compensation Set Aside Web Portal About This Site CMS Links How To Reference Materials Contact Us Case Information Beneficiary Claimant d Diagnosis Codes WC Carrier Employer ll Attorney Notes 1 Documents Summary i Case Notes QUICK HELP To add a note type your
117. on Once all corrections have been made click Next at the bottom of that page to navigate back to the Case Summary page Case Summary PR I Print this page Beneficiary Claimant Diagnosis Codes WC Carrier Employer Attorney Notes Documents Summary Please review your case information Please note that a consent form is required prior to case submission If you need to change the information click the Edit button If you are satisfied with the information click the Submit Case button to submit the case Click Cancel Case Creation to cancel the process all data will be lost Click Save Work In Progress button to save entered data Print this page for your records Claimant Information Diagnosis Codes Last Name LAST MI M First Name FIRST Diag Code 933 Date of Birth MONTH HHH Diag Code 5933 Date of Injury MONTH Aa HICN gemman SSN eee Ee WC Carrier Employer Insurer Name AAAAAAAAAAAA Employer Name AAAAAAAAAAAA Policy Number ppp EIN AHHH Claim Number 44449 Claimant Attorney Last Name LAST MI M First Name FIRST Attorney E mail AAAAAAAAAA Notes Information Documentation Save Work In Progress Submit Case Cancel Case Creation Submit the Case You still have the option to save the case as a Work In Progress on this page However if all case information is complete and you are ready to submit the case click the Submit Case button The Submit Case button is
118. one number e For Representative Accounts o Representative contact information name social security number mailing address e mail address phone o Beneficiary last name and first initial o Beneficiary Social Security Number SSN or Health Insurance Claim Number HICN o Beneficiary date of birth o Beneficiary gender e For Self Accounts o Contact information name mailing address e mail address phone o Social Security Number SSN or Health Insurance Claim Number HICN o Date of birth o Gender It is imperative that all E mail addresses entered are correct To successfully register yourself or your organization and create an Account ID follow the steps outlined below 1 Enter the following URL into your Web browser https www cob cms hhs gov WCMSA 2 The Login Warning page displays detailing the Data Use Agreement DUA The Login Warning page can be printed by clicking the Print this Page link in the upper right of the page Rev 2011 6 December 8 WCMSAP User Manual Chapter 3 New Registration CENTERS for MEDICARE amp MEDICAID SERVICES CATS Workers Compensation Medicare Set Aside Web Portal Login Warnin Print this page UNAUTHORIZED ACCESS TO THIS COMPUTER SYSTEM IS PROHIBITED BY LAW This web site is maintained by the U S Government and is protected by federal law Use of this computer system without authority or in excess of granted authority such as access through use of another
119. or accuracy then signed and returned to the COBC You cannot submit view or create cases until the signed Profile Report is received by the COBC After the report has been received by the COBC you can login to the account to maintain account and case information upload and replace documents submit cases and manage Designee access You may choose to manage the entire account or you may invite other company employees to assist as Account Designees Corporate and Representative accounts only To add Designees to a WCMSAP account you must login to the WCMSAP site using the Login ID and Password you created during the Account Setup process Chapter 8 describes the steps you must take as the Account Manager to invite users to be Account Designees Chapter 9 details the Account Designee self registration process once they have received an invitation E mail from the COBC after you add them to your account Profile Report Upon completion of all information for the account setup an E mail notification will be sent to you and the Account Representative for Corporate accounts or to you only for Representative and Self accounts The E mail will also include a Profile Report noting all information previously recorded during registration and any additional information provided during the account setup Refer to Chapter 15 for a sample notification E mail and Profile Report It may take up to 10 business days to receive the Profile Report Contact the
120. ormation must be provided Last Name First Name Address Line 1 City State Zip Code and Phone Last Name First Name M Address Line 1 Address Line 2 City State Select M Zip Code Phone Fax Attorney E mail Address Re enter Attorney E mail Address Save Work In Progress _ Case Summary Cancel Case Creation Beneficiary Claimant Attorney Page Field Description Last Name Enter the attorney s last name First Name Enter the attorney s first name MI Enter the attorney s middle initial Address Line 1 Enter the first line of the attorney s mailing address Address Line 2 Enter the second line of the attorney s mailing address City Enter the city where the attorney is located State Select the state where the employer is located from the dropdown list Zip Code Enter the attorney s zip code Phone Enter the attorney s phone number Fax Enter the attorney s fax number Attorney E mail Address Enter the attorney s E mail address Re enter Attorney E mail Address Re enter the attorney s E mail address The address must be manually entered it cannot be copied and pasted Command Buttons Previous Click to return to the WC Carrier page Rev 2011 6 December 72 WCMSAP User Manual Chapter 10 Create a New Case Beneficiary Claimant Attorney Page Field Description Next Click to save changes and continue to the next page Save Work In Pr
121. our registered E mail address If you do not receive an E mail within 24 hours contact a COBC EDI representative CMTS Workers Compensation Set Aside Web Portal PA de A A AD Thank You Your pasteord for the Workers Compensation Me caro Set Asado Portal WCIASADP has been successhuly reset NEXT STEPS You will recen an E mail with a temporary password and mstrachons to follow Please note The E mail message wil be sent bom a notiication ondy address that cannot accept incoming E mad Please do not reply to you do not receive your Emad within 24 hoors please call the COOC EDI Departmert at 646 4586740 EDI Representatves are avaiable to asset you Monday through Fndsy excluding Federal holidays tom 900 am to 500 pm Eastern Time Workers Compenaresn Medeae Set Asnte Welcome Page 5 Click the Workers Compensation Medicare Set Aside Welcome Page link to return to the Welcome page 6 You must change your temporary Password the next time you log into the WCMSAP Refer to the Change Password section in Chapter 7 for more information Rev 2011 6 December 40 WCMSAP USER MANUAL Chapter 6 WCMSAP Home Page The WCMSAP Home page is the first page displayed after a successful login This page functions as the main processing page to initiate all WCMSAP functions In addition to the original Navigation Menu options a Log Off link displays which will log you out of the WCMSAP and return you to the Login Wa
122. pper case letter one lower case letter one number and one special character e Password must contain a minimum of four 4 changed characters from the previous password Password cannot be changed more than once per day e Password must be different from the previous 6 passwords e Password cannot contain a reserved word See Help About This Page for a complete list An asterisk indicates a required field Login to A Password po Re enter Password MA E The Security Questions allow you to regain account access if you forget your password Please note the answers you provide to these questions should be actual answers and not hints for your password Choose Security Questions and Provide Answers Security Question 1 PleaseSelect sw Security Question 2 Please Select vi Answer 2 ETA 4 Using the posted guidelines create a Login ID and enter and re enter a Password Select 2 Security Questions and Answers and click the Next button You will use your Login ID and Password to enter the WCMSAP site and manage the account manage designees create and view cases and upload file attachments The Security Questions will allow you to access your Login ID and reset your Password in the event you forget either one The Account Manager Summary page displays This page lists information that was previously entered during the account setup process All information should be reviewed and verified before continuing R
123. r AR has ultimate accountability for the company s compliance with WCMSAP submission requirements Although the AR does not have direct access to the WCMSAP application and cannot be a user on the portal the AR must approve the organizations profile during the initial account setup and through any subsequent changes The AR is also the recipient of the more severe error notifications such as non compliance An AR cannot also be defined as an Account Manager AM or Account Designee AD for any account The AR e Performs the New Registration step on the WCMSAP but is not provided with a Login ID They can NOT be an actual user of the system e Designates the AM e Must approve the account setup by physically signing the Profile Report including the Data Use Agreement and returning it to the COBC Change your Account Representative by using the Update Corporate Information process as described in Chapter 7 Account Manager AM Role Each WCMSAP Account must have an assigned Account Manager AM The AM is established during the account setup process Each WCMSAP account can have only one AM This is the individual who controls the administration of an organization s account and manages cases which includes managing case access The AM can only be associated with one WCMSAP account The AM is a registered user of the system AMs have unlimited access to WCMSAP functionality and cases The submitter for Self account types is by def
124. rative disciplinary action and civil and criminal penalties including civil monetary penalties For site security purposes we employ software programs to monitor and identify unauthorized access unauthorized attempts to upload or change information or attempts to otherwise cause damage In the event of authorized law enforcement investigations and pursuant to any required legal process information from these sources may be used to help identify an individual and may be used for administrative criminal or other adverse action Privacy Act Statement The collection of this information is authorized by 42 U S C 1395y b 5 The information collected will be used to identify and recover past mistaken Medicare primary payments and to prevent Medicare from making mistakes in the future for those Medicare Secondary Payer situations that continue to exist Attestation of Information have submitted all relevant information obtained and or have knowledge of regarding this claimant that was generated at any time on or after the Date of Incident DOI for the alleged accidentillness injury incident at issue and has been included as part of this submission of the proposed amount for this WCMSA to the Centers for Medicare amp Medicaid Services The information provided is complete truthful accurate and meets all requirements set forth to use this process and have read and understand all of the Centers for Medicare amp Medicaid Services inform
125. rd issued after you completed the Forgot Password process Your Password can only be changed once every 24 hours 1 On the Home page click the Change Password link in the Account Settings box on the right side of the page Account Settings Update Personal Information Update Account Information Designee Maintenance View Account Activity Change Password 2 This displays the Change Password page Change Password Choose your password carefully An asterisk indicates a required field Enter your current password Enter your new password Re enter your new password Home About This Site CMS Links Workers Compensation Set Aside Web Portal e Password must be changed every sixty 60 days Password must consist of at least eight 8 characters Password must contain at least one upper case letter one lower case letter one number and one special character e Password must contain a minimum of four 4 changed characters from the previous password Password cannot be changed more than once per day Password must be different from the previous 6 passwords e Password cannot contain a reserved word See Help About This Page for a complete list 3 Enter your Current Password 4 Enter and re enter a new Password following the listed guidelines then click Continue 5 The Change Password Confirmation page displays Rev 2011 6 December How To Help A
126. re registered under Use the fields on the page to narrow the displayed alerts CMTS Workers Compensation Set Aside Web Portal CENTERS for MEDICARE amp MEDICAID SERVICES Home About This Site CMS Links How To Reference Materials Contact Us Logoff Alerts Help About This Page This page lists all alerts that correspond to the Account ID s you are registered under You can select a notification to view by clicking on the Alert ID The data is sorted by Creation Date and Case Number descending You can perform a search by entering the search criteria and clicking the Search button Case Control Number Status All v Hen TJ or ssn il Alert Creation Date Range From Date MM DD CCYY To Date r MM DDICCYY Alert ID Creation Date Alert Type Case Number Creator Status HICN SSN Bene Name 1 2010 02 15 Development 123456 RO Open Deny 987654 WCRC Archived Rev 2011 6 December 88 WCMSAP User Manual Chapter 12 View Alerts Alert Lookup Page Field Description Case Control Number Enter the case number received on the alert Status Enter an alert status to filter by Options are Read Unread Archived or Not Archived HICN Enter a Health Insurance Claim Number If you enter a HICN do not enter an SSN SSN Enter a Social Security Number If you enter an SSN do not enter a HICN Alert
127. rn to the Home page An asterisk indicates a required field The Beneficiary Claimant s Social Security Number SSN or Health Insurance Claim Number HICN must be provided You may not provide both HICN OR SSN Initial Date of Injury MM DD CCY Y Last Name First Name Gender Select Date of Birth MM DD CCY Y Proposed Settlement Amount 00 New Case Creation Page Field Description HICN Enter the beneficiary or claimant s Health Insurance Claim Number If you enter the HICN you can NOT enter an SSN SSN Enter the beneficiary or claimant s Social Security Number If you enter the SSN you can NOT enter a HICN Rev 2011 6 December 63 WCMSAP User Manual Chapter 10 Create a New Case New Case Creation Page Field Description Initial Date of Injury Enter the date of the beneficiary or claimant s first injury If there are additional dates of injury for this case add them on the Case Notes page If there are additional dates of injury for this beneficiary claimant that are NOT associated with this case a separate case or cases must be submitted Last Name Enter the beneficiary or claimant s last name First Name Enter the beneficiary or claimant s first name Gender Select the beneficiary or claimant s gender from the drop down list Date of Birth Enter the beneficiary or claimant s date of birth Proposed Settlement Amount Enter t
128. rning page The Home page gives you access to all functions in the WCMSAP From this page you can e Update your Personal Information your name address e mail phone e Update Account Information organization name address e mail phone AM function only e Manage Account Designees AM function for Corporate and Representative accounts only e View Account Activity e Change your Password e Create a New Case e Search for an Existing Case o Submit a Work In Progress case o Add or replace files on a submitted case o Manage Designee access to cases e View Case Alerts CMTS Workers Compensation Set Aside Web Portal CENTERS for MEDICARE amp MEDICAID SERVICES About This Site CMS Links How To Reference Materials Contact Us WCMSAP The WCMSAP provides an interface for entry of Workers Compensation Help About This Page Medicare Set Aside WCMSA proposals You may use this site to enter the case information directly The site also provides the ability to track submitted cases and the statuses without inquiry to COBC or CMS Case Lookup and View Alert functions are also available Click the desired link below to perform Account Settings that function Update Personal Information You may modify Account Settings by clicking the appropriate link under the Account Settings list Update Account Information I d like to Designee Maintenance A m view Account Activity Create a New Case Change Password Ca
129. s Enter your E mail address Note If your E mail address is found in the system as an existing user you will NOT be allowed to continue the registration process Re enter E mail Address Enter your E mail address a second time for verification purposes Phone Enter your phone number The Extension field is optional Address Line 1 Enter the first line of your mailing address Address Line 2 Enter the second line of your mailing address Optional City Enter the city where you are located Sii Select the state where you are located from the drop down list ate Note To quickly select a state type the first letter to scroll to the desired state Zip Code Enter your Zip Code Required plus 4 digit Zip code suffix Optional Command Buttons Previous Click to return to the Select Account Type page Next Click to save changes and continue to the next page 2 Enter the required information then click Next The Registration Summary page displays This page lists all the information that was previously entered All information should be reviewed and verified before continuing Rev 2011 6 December 21 WCMSAP User Manual Chapter 3 New Registration CMTS Workers Compensation Medicare Set Aside Web Portal CENTERS for MEDICARE amp MEDICAID SERVICES Home About This Site CMS Links How To Reference Materials Contact Us Logoff Registration Summary i ee
130. s AAAAAAAAAA Phone HHE HHE ext HHH Fax ARRAS Help About This Page QUICK HELP 3 This displays the Corporate Information Update Confirmation page showing what information has been updated Rev 2011 6 December 44 WCMSAP User Manual Chapter 7 Account Settings CENTERS for MEDICARE amp MEDICAID SERVICES CMTS Workers Compensation Set Aside Web Portal About This Site CMS Links How To Reference Materials Contact Us CA gt Print this p QUICK HELP Corporate Information Update Confirmation aot Help About This Page Your corporate information has been updated Print this page for your records Account Type Corporate Corporate Information Account Representative Information Employer Identification Number EIN pes First Name FIRSTMI M Last Name LAST Corporate Name AAAAAAAAAAAA Title AAAAA Date of Birth 44 44 44 Business Mailing Address Address Line 1 AAAAAAAAAAAA Fax HR Return to Home 4 Click the Return to Home button to return to the Home page The system then sends you an E mail indicating that the account information has been changed View Account Activity All activity performed for an Account ID can be reviewed The system provides an Account Activity history page that lists Activity Date Description and User Typical activity recorded includes e Initial Registration Account Setup Account Manager Registration Add Designee Delet
131. s you must determine your account type There are three types of WCMSAP accounts Corporate Representative and Self Account types are mutually exclusive you can only select one account type e Corporate account type indicates that the submitter is registering as a corporate entity with an Employer Identification Number EIN Those registering as a Corporate account will regularly submit WCMSAP cases e Representative account type is for non corporate WCMSAP users These submitters do not have an EIN but will submit multiple cases e Self submitters are Medicare beneficiaries or individuals with a reasonable expectation of becoming a Medicare beneficiary within 30 months who wish to submit a case for themselves The account type selected determines both the basic information that is captured during the registration process and the level of vetting that is subsequently undertaken Rev 201 1 6 December 1 WCMSAP User Manual Chapter 1 Introduction User Roles The WCMSAP permits multiple users per account to take part in the account registration and case submission processes Each user is defined by one of three possible roles and each user can only have one role within the WCMSAP Account Representative AR Role The Account Representative AR role is for Corporate account types only Your AR is the individual who has the legal authority to bind the company to a contract and the terms of WCMSAP requirements and processing You
132. s been created neither the SSN nor HICN can be changed within the case If the SSN and or HICN are incorrect the case must be e Canceled if it has not been saved as a Work In Progress e Deleted if it has been saved as a Work In Progress OR e Closed and re created with the correct HICN or SSN if the case was submitted Contact the EDI Department to close a submitted case See the following sections for more information on removing cases All files being added to a case must be in PDF format can be no larger than 40 MB total for all files being attached up to 3 files and must be virus free Ensure that all files related to a case have been converted to that format and do not exceed size limits This is especially important for medical records You may have to separate medical records into multiple files to meet size limitations All PDF files that meet the noted criteria can be added to a case You do not have to complete the case creation process immediately You can save the entered information at any time after the initial case creation page by clicking the Save Work In Progress button that displays at the bottom of most pages If you do so the case is saved and the Work In Progress page displays CMTS Workers Compensation Set Aside Web Portal CENTERS for MEDICARE amp MEDICAID SERVICES Home About This Site CMS Links How To Reference Materials Contact Us Logoff Case Saved as Work In Progress WIP You have succ
133. s by entering your selected criteria then click Search The Alert Lookup page redisplays with information listed for alerts that matches the search criteria only Click the Alert ID number link to view Alert Detail page which displays a specific alert or letter Click the Case Number link to view the Alert Listing page which shows all alerts for the case Rev 2011 6 December 89 WCMSAP User Manual Chapter 12 View Alerts Alert Listing This page displays all alerts associated with the selected case number CATS Workers Compensation Medicare Set Aside Web Portal About This Site CMS Links How To Reference Materials Contact Us Alert Listing Case Number HHHHHHHHHHHHHHE This page lists all the alerts for the selected case The data is sorted by Alert Creation Date descending AlertID Alert Creation Date Alert Type Creator Status HICN SSN Bene Name 122 01 31 2011 Under Threshold WCSA READ REA FIRST LAST 125 01 31 2011 Denied WCSA READ eB FIRST LAST Click the Alert ID number link next to an alert to view the Alert Detail page Rev 2011 6 December 90 WCMSAP User Manual Chapter 12 View Alerts Alert Detail The Alert Detail page displays the selected alert Most alerts are accompanied by letters In most instances the Alert Detail page will display the contents of the letter in PDF format Where possible please submit any requested documents via the website instead of faxing or mailing Archiv
134. se Lookup View Alerts Rev 2011 6 December WCMSAP USER MANUAL Chapter 7 Account Settings Access to functions in the Account Settings box is limited by user role Account Managers e Update Personal Information Update Account Information Designee Maintenance Corporate and Representative accounts only View Account Activity Change Password Account Designees Corporate and Representative account types e Update Personal Information e View Account Activity e Change Password Update Personal Information Your personal information is recorded during your initial registration process However this information can be updated and changed if necessary 1 Onthe Home page click the Update Personal Information link in the Account Settings box Account Settings Update Personal Information Update Account Information Designee Maintenance View Account Activity Change Password 2 This displays the Update Personal Information page Rev 2011 6 December 42 WCMSAP User Manual Chapter 7 Account Settings About This Site CMS Links Reference Materials Update Personal Information An asterisk indicates a required field First Name FIRST M M_ LastName LAST Date of Birth MM DD CCYY E mail Address AAAAAAAAAA Re enter E mail Address AAAAAAAAAA Phone sse _ e e ext eses
135. ssscsssesssssessesesesecsnecsneeseessesseessesssess 42 Update Personal Information t ae hse bande Miwa ieee athe a 42 Update Account Information viii speek snddesetcegtbuandncdoendedgouspsncdesed deasboehdoedeeoednsW eesenedd 44 VIE WA CCOUME ACHIVILY 55 cosssagsuaevased oaks ids dees ca idos 45 Change Password site tito eeaeee o ar aea a aed dat gp OEE EEEO Ee oa Ei eara 47 Chapter 8 Designee Maintenance scccscccccscscscssscscssccsccssscssscsscssecssccsscssecsscssscssscsssssesscssssesesecsseeseessecssesssesssess 49 Rev 2011 6 December ii WCMSAP User Manual Table of Contents Addi Designee sionin n r a a at died 49 Delete a Designee a A AAA a deh De As tE 53 Edit Designee Informal ed ts oct sal a ES aR E RE A EESO Eea seb ceceveoneeeupestareed 54 Regenerate Invitan Em a i aE EARE A A Aa A EEE EA ai R EEE 55 Chapter 9 Account Designee Registration sessessessesessoesessossesoesseseesossessossesoessesoesoesessossesoossesoesssseesossessossessessso 56 Chapter 10 Create a New Case cccscccsccssscssccscscscssccsssesscssscsesenecsscesscssscsscsscssscssscsssssssscssesecenecsseesoesscsseessesssess 62 Case Creation OVEIVIe Women dicas coin ches de euitede Boiss Monette cocidas ants aid tetas iii 62 New Case Creatina da 63 Beneficiary Claimant Information cccccsccccscecescceessecseeceesecssceeescecssceeeasecseceeeacecseeeecsaecseneeesaecseneeeaaeceeneeeaeceeeeeeaeeees 65 DDIGSNOSTS COGES viassets 25 ce hance seteis
136. st accept and agree to the terms of the User Agreement in order to continue through the registration process 2 Enter the required personal information accept the User Agreement then click Next For Representative accounts all fields will be populated with the contact information you entered earlier if you click the Same as Submitter button This button does not display for Corporate or Self Rev 2011 6 December 31 WCMSAP User Manual Chapter 4 Account ID Setup amp Account Manager Registration accounts For Self accounts all fields will be automatically populated with the contact information you entered earlier Note You can register as an Account Manager for an account if you are already a registered Medicare Medicaid and SHIP Extension Act 2006 MMSEA Mandatory Reporting user If you are a new user the Account Manager Login Information page displays requesting you to set up a Login ID and Password using the following guidelines Additionally 2 Security Questions must be selected Otherwise this page is skipped Login IDs must be 7 characters Login IDs must be in the format of AA999AA first two alphabetic next three numeric last two alphabetic Login ID and Password cannot be the same Passwords must be changed every 60 days Passwords must be 8 characters in length Passwords must contain at least one upper case letter one lower case letter one number and one special character Passwords c
137. submitted case by using the case lookup process and utilizing the case number provided on the Successful Case Submission page Manage Case Access Account Managers for Corporate and Representative accounts can use this page to grant or revoke Account Designees access to specific cases under an Account ID After clicking the Manage Access link on the Case Listing page or the Manage Access button on the Case Summary page the following page displays CMTS Workers Compensation Set Aside Web Portal About This Site CMS Links How To Reference Materials Contact Us Manage Case Access Case Information Case Number 123456 First Name FIRST Last Name LAST Date of Injury z5 Be SHEE Case Status Submitted Case Location WCRC HICN APPO SSN eS Create Date 02 15 2010 Submission Date 02 23 2010 Designee associations for the case You may select a designee by checking the checkbox next to their name To select all Designees click the Select All checkbox Designee Name Grant Revoke Access FIRST LAST Select All Gana The Manage Case Access page lists all ADs assigned to the Account ID If the AD currently has access to the selected case the checkbox will be checked If the AD does not currently have access to the case the checkbox will be empty To revoke AD access to a case remove the check To grant access place a check in the box Place a check in the Select All box to gr
138. sword Limits Each user of the WCMSAP can have only one Login ID and Password Unless previously registered all registrants are directed to the WCMSAP URL to register for a Web Portal account Users of the Mandatory Reporting application must use that same Login ID and Password to access the WCMSAP application Rev 201 1 6 December 3 WCMSAP User Manual Electronic Data Interchange EDI Representative Support Users of the WCMSAP may need assistance with managing an account or managing their personal information within the application If necessary you may contact an EDI representative for such assistance Contact an EDI representative if The Account ID and PIN letter is not received within 2 weeks 10 business days after completing the New Registration step The EDI representative can resend the letter allowing you to complete the account setup Any of the information entered during initial registration must be changed after the initial registration letter has been received You have any questions or problems regarding your account at any time during account setup You forget your Login ID and cannot remember the answers to your Security Questions The EDI representative can resend your Login ID to your registered E mail Address You forget your Password and cannot remember the answers to your Security Questions The EDI representative can generate a temporary Password and send it to your registered E mail Address You incorrec
139. t Settings box Account Managers only Account Settings Update Personal Information Update Account Information Designee Maintenance View Account Activity Change Password 2 This displays the Update Corporate Information page Your account s mailing and contact information is displayed on this page You can also update your Account Representative contact information or replace them with another person To make any corrections click the Edit button next to the proper section to return to that section Once all corrections have been made click Next at the bottom of that page to navigate back to the Update Corporate Information page After you have returned to the Update Corporate Information page click the Next button About This Site Update Corporate Information You may not change the Account Type Account Type Corporate Business Mailing Address Address Line 1 AAA AAAA Address Line 2 AAAAAA City AAAAAAAAAAAA Corporate Information Employer Identification Number EIN ereccion Corporate Name AAAAAAAAAAAA Workers Compensation Set Aside Web Portal How To Reference Materials Contact Us CA Print this page You may edit the account information or Account Representative information by clicking on the Edit button of that section Account Representative Information First Name FIRSTMI M Last Name LAST Date of Birth 44 44 4444 E Mail Addres
140. t information This action may result in the non payment of the Medicare beneficiary s claims that are related to the workers compensation injury or illness Note The case will automatically reopen when the requested information is received If you have any questions regarding our request for additional information please contact the undersigned at 301 575 0160 Sincerely RoName Rev 2011 6 December 120
141. te Alert Types are Below Threshold Development Deny Zero Set Aside Under Threshold Approval Closeout Co Mingled Documentation and Deceased Beneficiary Please log into the web site https www cob cms hhs gov WCMSA to review the alert details PLEASE DO NOT REPLY TO THIS E MAIL Confidentiality Note This electronic message transmission is intended only for the person or entity to which it is addressed and may contain information that is privileged confidential or otherwise protected from disclosure If you have received this transmission but are not the intended recipient you are hereby notified that any disclosure copying distribution or use of the contents of this information is strictly prohibited If you have received this e mail in error please contact the COBC Electronic Data Interchange EDI Department at 646 458 6740 and delete and destroy the original message and all copies EEES Rev 2011 6 December 110 WCMSAP User Manual Chapter 15 Sample WCMSAP Correspondence Alert Letters Below Threshold Letter Beneficiary CMTS CENTERS for MEDICARE amp MEDICAID SERVICES MEDICARE Coordination of Benefits 1 800 999 1118 or TTY TDD 1 800 318 8782 Name RE Workers Compensation Medicare Set aside Arrangement for Claimant Claimant HICN SSN HicnSsn Date of Injury DateOfInjury CMS Case Control Number Caseld Dear Sir or Madam The Centers for Medicare amp Medicaid
142. tenance or other system specific information WCMSAP Messages This space is reserved for system messages from the Coordination of Benefits Contractor Check this location for important information regarding system outages scheduled maintenance and special announcements Rev 2011 6 December 6 WCMSAP User Manual Chapter 2 WCMSAP Welcome Page New Registration The designated Account Representative AR must click on the New Registration button under Step 1 to complete and submit the registration information It is critical that you provide the AR s information including E mail address in this New Registration step and NOT the E mail address for someone you want to be a user of the WCMSAP For Corporate accounts only Users registering Representative and Self accounts are permitted to access the WCMSAP Refer to Chapter 3 for more information on account registration Account Setup After completion of the New Registration step the COBC will mail a confirmation letter containing the Account ID and PIN to the AR for Corporate accounts or you for Representative and Self accounts along with instructions for setting up the account The assigned AM should click the Account Setup button under Step 2 to finish the account setup using the Account ID and PIN and to register themselves as the AM For Corporate accounts the AM receives the Account ID and PIN from the AR Refer to Chapter 4 for more information on account setup
143. teps in the account setup process CATS Workers Compensation Medicare Set Aside Web Portal CENTERS for MEDICARE B MEDICAID SERVICES About This Site CMS Links ow Reference Materials Contact Us Thank You CR Print this page You have successfully completed the Account Setup for the Workers Compensation Medicare Set Aside Web site and established yourself as the Account Manager for the Account ID Please print this page for your records Next Steps You may return to the Workers Compensation Medicare Set Aside Web site Welcome page login using the Login ID and Password you just created to access accounts associated to your ID Please note when returning your profile to the COBVA mailbox please write WWCMSAP Profile Report in the subject line This is so the EDI Reps responsible for routing COBVA messages know to who they should send profile reports You can visit the Workers Compensation Medicare Set Aside page at Workers Compensation Set Aside Welcome Page Rev 2011 6 December 34 WCMSAP User Manual Chapter 4 Account ID Setup amp Account Manager Registration 7 Click the Workers Compensation Medicare Set Aside Welcome Page link to return to the Welcome page You have successfully setup the account and registered yourself as the Account Manager As the AM you control the administration of the WCMSAP account You will receive a Profile Report from the COBC via E mail which must be reviewed f
144. the Designee s information for the individuals you have assigned to the account An Account Manager can only make changes to a pending Designee Once the Designee has registered and has a Login ID the Account Manager cannot make changes to the Designee information other than deleting the Designee from the account To make changes to the account of a particular Designee listed select the link on the individual s last name To delete a Designee select the Delete function to the left of the individual s name Use the Add a Designee function to include an individual as a designee Individuals added as designees will receive an e mail notifying them that they have been invited to be a designee for the account Delete Last Name First Name E mail Address Passphrase Status x LAST FIRST AAAAAAAAAAAA AAAAAAA Active x LAST FIRST AAAAAAAAAAAA AAAAAAA Pending Rev 2011 6 December 49 WCMSAP User Manual Chapter 8 Designee Maintenance 3 To print the Designee Listing page click the Print this Page icon in the upper right corner To return to the Home page without making any changes click the Return to Home button 4 To add an Account Designee click the Add a Designee button under the Account Designee List The Designee Information page displays CATS Workers Compensation Set Aside Web Portal Home About This Site CMS Links How To Reference Materials Contact Us Logoff Designee Information Please click the Next button to check
145. this case was submitted using the Worker s Compensation Set Aside Web Portal the final settlement document must be attached and submitted to the case using the Web Portal See the Case Documents section 25 Proposed Final Settlement Agreement or Court Order on the Web Portal case If you have any questions concerning this letter please call RoContact at RoPhone Sincerely Cold Webi Gerald Walters Director Financial Services Group Office of Financial Management CcClaimName CcClaimAtty CcLeadCntr Rev 2011 6 December 119 WCMSAP User Manual Chapter 15 Sample WCMSAP Correspondence Closeout Letter CMTS CENTERS for MEDICARE amp MEDICAID SERVICES MailDate SubName RE Workers Compensation Medicare Set aside Arrangement for Claimant Claimant HICN Hicn SSN SSN Date of Injury InjuryDate CMS Case Control Number Caseld Dear SubName2 MEDICARE Coordination of Benefits 1 800 999 1118 or TTY TDD 1 800 318 8782 We recently requested additional information from your office to determine the appropriate Medicare set aside for the claimant named above Since that time either 10 business days have expired without our receiving a reply or the reply we received did not include what we need We still need lt lt Free Text gt gt Therefore we are closing this case and treating it as ineligible for review due to lack of sufficien
146. tion A Profile Report is generated after the account setup has been completed successfully Please review the attached Profile Report carefully and ensure all information is accurate In order to access all of the functions within the WCMSAP the report must be signed by the Account Representative and returned to the COBC Please send signed reports to via Fax 646 458 6761 via E mail COBVA GHIMedicare com via mail MEDICARE COB Section Reporting Program P O Box 660 New York NY 10274 0660 If the report is incorrect please contact our Electronic Data Interchange EDI Department at the number or e mail address listed below to resolve any error Phone 646 458 6740 E mail COBVA GHIMedicare com Confidentiality Note This electronic message transmission is intended only for the person or entity to which it is addressed and may contain information that is privileged confidential or otherwise protected from disclosure If you have received this transmission but are not the intended recipient you are hereby notified that any disclosure copying distribution or use of the contents of this information is strictly prohibited If you have received this e mail in error please contact the COBC Electronic Data Interchange EDI Department at 646 458 6740 and delete and destroy the original message and all copies EEES Rev 2011 6 December 101 WCMSAP User Manual Chapter 15 Sample WCMSAP Correspondence Workers Compensation
147. tly entered your PIN 3 times and locked the account The EDI representative can reset the PIN unlocking the account You have questions about case submission errors The EDI representative will work with you to understand the error and determine whether the case should be deleted and resubmitted or processed as submitted Contact the COBC EDI Department by phone at 646 458 6740 or by e mail at COBVA GHIMedicare com EDI representatives are available to assist you Monday through Friday excluding Federal holidays from 9 00 a m to 5 00 p m Eastern Time Rev 2011 6 December Chapter 1 Introduction WCMSAP USER MANUAL Chapter 2 WCMSAP Welcome Page The Welcome page is the portal to the WCMSAP for all WCMSA case functions Before the case submission process can begin the following steps must be taken and are done using this page For Corporate account types the organization must be registered and given an Account ID For Corporate account types the Account Representative must be named For Representative and Self account types the submitter must register and receive an Account ID The designated Account Manager AM must perform the Account Setup step for the Account ID The Account Manager AM must self register obtain a Login ID and create a Password Once the Account ID account and all users are registered the Welcome page is used to log in to the WCMSAP to manage the case submission process CENTERS for MEDICAR
148. ttach the selected file click the Attach Files button This uploads the document to the Case Documents page The file name and date the file was uploaded displays under the appropriate document category The new file name will appear under the proper document category replacing the previous file name The Replace link will still display to the right of the file name 05 Submitter Letter or Other Summary Documents Submitter Letter pdf 2010 01 20 Replace Add Files Delete Files To delete a document click the Delete link that appears to the right of the file name This permanently removes the document from the WCMSAP You can only delete documents from new and WIP cases and documents that have been added but not yet saved to an existing case You cannot delete files that were previously saved to existing cases Submit a Work In Progress Case Once all case information is complete and you are ready to submit a Work In Progress case click the Submit Case button at the bottom of the page This button only displays for cases in WIP status The Successful Case Submission page displays Rev 2011 6 December 85 WCMSAP User Manual Chapter 11 Manage Existing Cases Workers Compensation Set Aside Web Portal About This Site CMS Links Reference Materials Contact Us Successful Case Submission You have successfully submitted Case Number 234576 You can return to the WCMSAP at a later time and work on the
149. ual Chapter 11 Manage Existing Cases Case Summary Use the Case Summary page to add documents to a case replace documents on submitted cases delete documents on Work In Progress cases and submit WIP cases from this page Corporate and Representative Account Managers can also view the Manage Case Access page from here Click the View button next to a section heading to display the entered information Click the Next button at the bottom of that page to navigate back to the Case Summary page or click the Case Summary button at the bottom of any page to return to the Summary page CMTS Workers Compensation Set Aside Web Portal CENTERS for MEDICARE amp MEDICAID SERVICES About This Site CMS Links How To Reference Materials Contact Us ER Print th Case Summary Print this page Beneficiary Claimant Diagnosis Codes WC Carrier i Employer i Attorney i Notes Documents Summary The following is the information submitted for the case If you need to view the details click the applicable View button Click the Add Files button to transfer to the Case Documents screen If you would like to review or change the indiviuals assigned to this case please click the Manage Access button You may print this page for your records Case Number 123456 Alerts View Beneficiary Claimant Information Diagnosis Codes Last Name LAST MI M First Name FIRST Diag Code 933 Date of Birth MONTH 4 4 Diag Code
150. uatestsaesncesagsus ovbsssseeylapevtestosecbeseasseees 93 Replace Account Manager iran optan nata pipa 93 Unsuccessful Account Registration iii iaa ara aaa deter qee escasa 93 Previously Used EIN ocios mi us eE ous re SEE E AE EE E OE E EEEE S agen ca e piece 93 Rev 2011 6 December iii WCMSAP User Manual Table of Contents Previously Used SS Nociones 93 Registration Demed inma 93 Unsuccessful Account SellPiinn ni e e ae dan ca EEE S EE 93 Account PIN Erre s 93 Account ID Already Registered n eenei e oe E E E S EE ii 94 Account Manager and Account Representative E mail Addresses Match oooooonncccnonoccocccnonnnconccnnnncnnnccnnnncnnnccnnno 94 Unsuccessful Account Designee Invitation ccccscceeceecceescesscesecesecsecasecasecseeeseeeseesseeseeeecssecssecsaecsaecsaecaeeeseeeaeees 94 Account Designee E mail Address Matches Account Representative or Account Manager E mail Address 94 Account Designee E mail Address Matches Account Designee Already Associated with the Account 94 Unsuccessful Account Designee Registration cccccccccessceecesscesecesecnsecsecsecseeeseesseeeseeseseecesecaecaecuaecsaecaaeeseeeaeees 94 Incorrect Passphrase iscciscsesc sce estera e boca cheek E rE EEE E EEEE E TE dhe r ES E AEE EErEE 94 UNSUCCESSFUL Lopine a A Ne Gs a aes haere as A as A ee Para Aoi a Oae Erop E 95 Invalid Losin DD es nit lan 95 Inactive Login ID eutanasia meena 95 Revoked Login A O NN 95 Invalid Password ect EEE E E
151. uestions should be actual answers and not hints for your password Choose Security Questions and Provide Answers Security Question 1 PleaseSelect sw Security Question 2 Please Select vi Answer 2 ETA 9 Enter the required information and click the Next button 10 The Designee Summary page displays The page provides a summary of all the information you have entered To make any corrections click the Edit button next to the proper section to return to that section Once all corrections have been made click Next at the bottom of that page to navigate back to the Designee Summary page After you have returned to the Designee Summary page click the Submit Registration button Rev 2011 6 December 60 WCMSAP User Manual Chapter 9 Account Designee Registration Workers Compensation Set Aside Web Portal Home About This Site CMS Links How To Reference Materials Contact Us Logoff y CA Designee Summary Print this page Please review your personal and login Information If you need to change the information click the Edit button If you are satisfied with the information click the Continue button to submit your information Click Cancel to cancel the setup process all data will be lost Print this page for your records Login ID Personal Information First Name FIRST MI M Last Name LAST Login ID AA123bb E Mail Address AAAAAAAAAA Phone HH HH HHH ext HHH Mailin
152. unt Designee AD Role At the organization s discretion an Account Manager AM for Corporate or Representative account types may invite other individuals known as Account Designees ADs to have access to the WCMSAP for the AM s account Corporate accounts may have up to 20 ADs associated with one WCMSAP account Representative accounts may have up to 5 The AD e Must register on the WCMSAP and obtain a Login ID and Password e Can be associated with multiple WCMSAP accounts but only if invited by the AM for those accounts e Can change their personal information on the WCMSAP e Cannot be an Account Representative AR for any WCMSAP account e Cannot be the AM for the same WCMSAP account e Cannot invite other users to the WCMSAP account e Cannot update WCMSAP account information e Can submit new cases for a given WCMSAP account e Can perform case lookups and view cases that they are associated with cases submitted by the AD or assigned to the AD by the AM e Can update append documentation to a case that they have been associated with e Can replace documentation for cases that they have been associated with e Can access alerts for cases that they have been associated with e Can update work in progress case information for cases that they have created or are associated with as assigned by the AM AMs can add remove or delete ADs using the Designee Maintenance process as outlined in Chapter 8 Login ID and Pas
153. ve In addition to processing cases the Account Manager will have the ability to designate Account Designees Representative Account The Account Manager will have the ability to process cases and to designate a limited number of Account Designees Self Account Under a Self account the registering individual will be the Account Manager No Account Designees may be added Next Steps To complete the account setup your designated Account Manager should be selected and provided with your WCMSAP Account ID and Personal Identification PIN WCMSAP Account ID HHH PIN HHH If you have any questions or concerns please contact the Coordination of Benefits Contractor COBC Electronic Data Interchange EDI Department at Phone 646 458 6740 E mail COBVA GHIMedicare com Sincerely Medicare Coordination of Benefits Contractor Rev 2011 6 December 100 WCMSAP User Manual Chapter 15 Sample WCMSAP Correspondence Profile Report E mail Notification Corporate Account From cobva ghimedicare com mailto cobva O ghimedicare com Sent Wednesday April 01 2009 2 42 PM To AAAAA AAA COM Subject Workers Compensation Medicare Set Aside Portal WCMSAP Profile Report Company Name AAAAAAAAAAAA Account Representative FIRST LAST Account Manager FIRST LAST The WCMSAP Profile Report has been attached to this e mail The Profile Report contains information regarding your company and the associated contact informa
154. viously recorded during registration and any additional information provided during the account setup Refer to Chapter 15 for a sample notification E mail and Profile Report It may take up to 10 business days to receive the Profile Report You will have 60 business days to review sign and return the Profile Report to the COBC When returning the signed Profile Report via email use WCMSAP Profile Report in the subject line If a signed Profile Report is not received within that timeframe the account will be automatically deleted on the 60 business day If the account is deleted you must start the registration process from the beginning Refer to Chapter 4 for more information on completing the account setup Rev 2011 6 December 15 WCMSAP User Manual Chapter 3 New Registration Representative Account Type 1 For Representative account types the Representative Information page displays Enter your personal information on this page The address you enter on this page will be used to send the Profile Report and any correspondence from the COBC regarding this Account ID Fields marked with an asterisk are required CENTERS for MEDICARE amp MEDICAJO SERVICES CMTS Workers Compensation Medicare Set Aside Web Portal O Home About This Site CMS Links How To Reference Materials Contact Us Logott Representative Information An indicates a required field First Name Social
155. we employ software programs to monitor and identify unauthorized access unauthorized attempts to upload or change information or attempts to otherwise cause damage In the event of authorized law enforcement investigations and pursuant to any required legal process information from these sources may be used to help identify an individual and may be used for administrative criminal or other adverse action Privacy Act Statement The collection of this information is authorized by 42 U S C 1395y b 5 The information collected will be used to identify and recover past mistaken Medicare primary payments and to prevent Medicare from making mistakes in the future for those Medicare Secondary Payer situations that continue to exist Attestation of Information have submitted all relevant information obtained and or have knowledge of regarding this claimant that was generated at any time on or after the Date of Incident DOI for the alleged accidentillness injury incident at issue and has been included as part of this submission of the proposed amount for this WCMSA to the Centers for Medicare amp Medicaid Services The information provided is complete truthful accurate and meets all requirements set forth to use this process and have read and understand all of the Centers for Medicare amp Medicaid Services information at http Wwww cms gowWorkersCompAgencySerices LOG OFF IMMEDIATELY if you do not agree to the conditions stated
156. will permanently remove the document from the Web Portal You will not be able to delete any files that were uploaded to the WCMSA Web Portal when the case was submitted An asterisk indicates a required file 05 Submitter Letter or Other Summary Documents Submitter Letter pdf 2010 01 20 Replace Add Files This displays the Attach Documentation page Rev 2011 6 December 84 WCMSAP User Manual Chapter 11 Manage Existing Cases CMTS Workers Compensation Set Aside Web Portal CENTERS for MEDICARE amp MEDICAID SERVICES Home About This Site CMS Links How To Reference Materials Contact Us Logoff Attach Documentation 05 Submitter Letter or Other Summary Documents Please type in the file name or click browse to find the file The file must be in PDF format and the size limitis 40 MB megabytes total for up to 3 files Please add any applicable notes To replace a document enter a new file name and path in the text box or use the Browse button next to the text box to search your system for the desired document Medical records must be separated into files that contain 100 or fewer pages If a beneficiary or claimant s medical records contain more than 100 pages create separate files before attaching the records Before attaching the file you can enter a note detailing what file was replaced and the reason for the replacement All notes will display on the Case Notes page To a
157. with Rev 2011 6 December 53 WCMSAP User Manual Chapter 8 Designee Maintenance Edit Designee Information An Account Manager can edit personal information for Designees in Pending status ADs in Pending status have not yet registered on the WCMSAP AMs can only view personal information for Designees in Active status 1 On the Designee Listing page click the last name of the Designee whose information you wish to update Delete Last Name First Name E mail Address Passphrase Status x LAST FIRST AAAAAAAAAAAA AAAAAAA Pending editing Home About This Site CMS Links How To Reference Materials Contact Us Logoff Update Designee Information Please click the Next button to check the E Mail Address of a potential designee To cancel and return to the Designee Listing page click the Previous button An asterisk indicates a required field We ask for the e mail address to verify if the person is currently a registered user First Name FIRST Last Name LAST E mail Address AAAAAAAAAA Re enter E mail Address Passphrase AAAAAAA Re enter Passphrase AAAAAAA Y Regenerate token Check this box if another invitation email must be sent to the Designee 3 Make the necessary changes and click Next 4 The Designee Listing page re displays with the Designee s personal information updated Delete Last Name First Name E mai
158. writing information related to my workers compensation injury and or settlement to the individual s and or firm s listed below This consent is for my current workers compensation claim and is on an ongoing basis An additional consent to release form will not be necessary unless or until I revoke this authorization which must be in writing PLEASE CHECK C Claimant s attorney name and or firm C Employer s attorney name and or firm C Workers compensation carrier name and or firm O Other name and or firm Claimant s Signature Date Signed Date of Injury Social Security Number Or Health Insurance Claim Number Rev 2011 6 December 115 WCMSAP User Manual Chapter 15 Sample WCMSAP Correspondence Approval Letter N SERV hh Ca y Sy J sa DEPARTMENT OF HEALTH amp HUMAN SERVICES Centers for Medicare amp Medicaid Services Name RE Workers Compensation Medicare Set aside Arrangement Claimant Claimant HICN Hicn SSN SSN Date of Injury DateOfInjury CMS Case Control Number Caseld Dear SubName2 This letter is in response to your initial proposal submitted on OrigDate for a Workers Compensation Medicare Set aside Arrangement WCMSA on behalf of the above named individual Paral Paral Payout Paral Cont Approval of this WCMSA is not effective until a copy of the final executed workers compensation settlement agreement which must include

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